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INTRACRANIAL    TUMOURS. 


INTRACRANIAL 
TUMOURS. 


BY 


BYROM  BRAMWELL,  M.D,  F.R.CP.E.,  F.R.S.E. 

LECTURER    ON    THE   PRINCIPLES   AND    PRACTICE   OF    JIEDICINE   IN   THE    EXTRA-ACADEMICAL 

SCHOOL    OF    JIEDICINE,    EDINBURGH  ;   ASSISTANT-PHYSICIAN    TO    THE 

EDINBURGH   ROYAL   INFIRMARY. 


WITH  ONE  HUNDRED  AND  SIXTEEN  ILLUSTRATIONS. 


PHILADELPHIA: 

J.    B.    LIPPINCOTT    COMPANY. 


EDINBURGH  :     PRINTED   FOR  VOUNG  J.    PENTLAND   BY  SCOTT   AND   FERGUSON, 
AND   BURNESS  AND   COMPANY,    PRINTERS   TO   HER  MAJESTY. 


PREFACE. 


The  following  pages  are  based  on  a  series  of  Lectures,  which,  in  the 
capacity  of  Lecturer  on  Clinical  Medicine  in  the  University  of 
Durham,  I  delivered,  now  some  ten  years  ago,  to  the  Students  of  the 
College  of  Medicine,  IsTewcastle-on-Tyne.  Portions  of  the  work  were 
communicated  in  the  form  of  three  Lectures  to  the  gentlemen  at- 
tending the  Edinburgh  Post-Graduate  Course  during  the  autumn 
of  last  year. 

The  work  is  essentially  based  upon  my  own  clinical  experience, 
but  I  have  not  hesitated,  whenever  it  has  seemed  necessary,  to  avail 
myself  of  the  opinions  of  other  observers.  In  particular,  I  have  to 
acknowledge  my  great  indebtedness  to  the  writings  of  Dr.  Hughlings 
Jackson,  of  whose  work  on  this  subject  British  Medicine  will  always 
be  justly  proud. 

My  sincere  thanks  are  due  to  Mr.  A.  W.  Hare,  M.B.,  FPt.C.S.E., 
for  the  chapter  on  the  Surgical  Treatment  of  Intracranial  Tumours 
which  he  has  kindly  w^ritten  for  me ;  also  to  Drs.  Clouston  and 
Carlyle  Johnstone  for  the  remarkable  specimens  of  Intracranial 
Aneurism  which  are  represented  on  pages  165  and  168 ;  to  Dr.  T. 
W.  M'^Dowall  for  the  Brain  represented  in  Fig.  113 ;  and  to  Dr.  David 
Drummond  for  the  cuts  of  his  cases  of  Perforating  Sarcoma. 


23  Dkumsheugh  Gaedens, 

Edinburgh,  1st  May  1888. 


CONTENTS 


CHAPTEE    I. 

DEFINITION — INTRODUCTION — ETIOLOGY — GENERAL  PATHOLOGY,  OR 
PATHOLOGICAL  PHYSIOLOGY. 

Influence  of  Injury  to  the  Head,  Mental  Anxiety,  Age,  Sex,  Occupation,  &c., 
in  the  production  of  Intracranial  Tumours — The  Effects  which  Intracranial 
Tumours  in  general  may  produce  upon  the  Brain  and  other  contents  of  the 
Cavity  of  the  Cranium  —  Detailed  consideration  of  the  chief  Causes  to  which 
the  Symptoms  of  Intracranial  Tumours  are  due- — Importance  of  increased 
Intracranial  Pressure,  Irritation,  Meningitis,  Cerebritis,  &c.  —  General  and 
Localising  Symptoms — Destroying  and  Discharging  Lesions — Pseudo-localis- 
ing  Symptoms — Influence  of  Complications  and  Associated  Lesions,  and  of 
the  "  Individuality  "  of  the  Patient,  ..... 


CHAPTER    II. 

SYMPTOMS  AND  CLINICAL  HISTORY — ANALYSIS  OP  INDIVIDUAL  SYMPTOMS. 

Clinical  Pictures  presented  by  different  cases  of  Intracranial  Tumour  —  Four 
great  Groups  —  Analysis  of  Individual  Symptoms  —  Headache,  "Vomiting, 
and  Vertigo  :  their  Characters,  Causes,  and  Diagnostic  significance,  .  19 

CHAPTER   III. 

CHANGES      IN    THE    FUNDUS     OCULI DOUBLE     OPTIC    NEURITIS     AND 

OPTIC    ATROPHY. 

Importance  of  Double  Optic  Neuritis  ;  its  Frequency  ;  Condition  of  Vision  in  ;  its 
Diagnostic  value — Optic  Atrophy  ;  its  Mode  of  Causation — The  Causation  of 
the  Double  Optic  Neuritis  associated  with  Intracranial  Tumours — The  chief 
Post-Mortem  Appearances  bearing  upon  the  Subject — Consideration  of  the 
different  Theories  in  detail  —  Importance  of  Leber  and  Deutschmann's 
Observations — Summary  and  Author's  Views,  ....  36 


CONTENTS. 

CHAPTER    W. 

MOTOR  DERAXGEMEXTS — PARALYSIS SPASM — TREMOR — CONTRACTURE. 


PAGE 


Paralysis  ;  its  Distribution,  Characters,  ^Slode  of  Causation,  and  Diagnostic 
value — Spasms  and  Convulsions — "Jacksonian"  Epilepsy — General  Epilepti- 
form Convulsions — The  comparative  value  of  Limited  Paralysis  and  Limited 
Convulsions  as  localising  Symptoms — Tonic  Spasms — Contractures — Choreic 
Spasms — Pbythmical  ]SIovements — Tremor — The  Condition  of  the  Bladder 
and  Rectal  Reflexes,   .  .  .  .  .  .  .  .63 


CHAPTEE    Y. 

SENSORY    DERANGEMENTS — TOUCH — SIGHT — HEARING — TASTE — SMELL. 

Derangements    of    the    Sensibility   of    the   Skin — Anaesthesia — Hypersesthesia — 
Derangements  of  the  Sense  of  Sight — Amblyopia — Hemianopsia — Importance 
-  of  exact  Perimeter  Measurements — Unilateral  Optic  Neuritis — Visual  Aura — 
Derangements  of  the  Senses  of  Hearing,  Smell,  and  Taste,  ...  88 

CHAPTEE    YL 

MENTAL    ALTERATIONS APHASIA APOPLECTIC    ATTACKS VISCERAL 

DERANGEMENTS. 

Positive  and  Negative  Mental  Symptoms — The  Causation  of  Mental  Symptoms — 
Derangements  of  Speech — Various  Forms  of  Aphasia — Their  Diagnostic  and 
Localising  Value — Apoplectic  and  Pseudo -Apoplectic  Attacks — Temperature — 
Pulse — Vaso-motor  Alterations — Polyuria  —  Glycosuria — Albuminuria — Bed- 
Sores — Derangements  of  Respiration,  .  ,  .  .  .109 


CHAPTEE   YIL 

DIAGNOSIS    AND    DIFFERENTIAL   DIAGNOSIS. 

Three  Steps  in  the  Diagnosis — Is  there  an  Intracranial  Tumour  ? — General  State- 
ment of  the  Principles  by  which  this  question  is  to  be  decided — Differential 
Diagnosis  of  Intracranial  Tumour  and  of  Bright's  Disease — Lead  Encephalo- 
pathy —  Hypermetropia,  with  or  without  Anaemia  —  Cerebral  Atrophy  or 
DiflFase  Chronic  Cerebritis — Migraine — Hysteria — Some  forms  of  Insanity 
— Meningitis — Cerebral  and  Cerebellar  Abscess — Extra-  and  Intracranial 
Syphilis — Cerebral  Haemorrhage,         .  .  .  .  .  .122 


CONTEXTS.  '  xi 

CHAPTER    YITI. 

DIAGNOSIS    COXTIXTED — THE   LOCALISATIOX    OF    THE    TUMOUR. 

PAGE 

General  Statement  of  the  Principles  by  whicli  the  Localisation  of  the  Tumour  is  to 
be  determined  —  Detailed  consideration  of  the  Symptoms  produced  by 
Tumours  of  the  Prontal  Lobe  —  Motor  Area— Post -Parietal  Region  and 
Occipital  Lobe — Temporo-Spheuoidal  Lobe  —  Centrum  Ovale — Corpus  Cal- 
losum — The  Base  of  the  Brain — Basal  Ganglia — Pons  Varolii  —  Corpora 
Quadrigemina  —  Pineal  Gland  —  Medulla  Oblongata  —  Cerebellum  —  The 
Differential  Diagnosis  of  Cerebellar  Tumour  and  of  Meniere's  Disease, 
and  Disseminated  Cerebro-Spinal  Sclerosis,     .  .  .  .  .         146 

CHAPTEE    IX. 

PATHOLOGICAL    DIAGNOSIS    A2sD    MORBID    AXATOMT. 

General  Statement  of  the  Principles  by  which  the  Pathological  Diagnosis  is  to  be 
determined  —  Detailed  Description  of  the  jSTaked-Eye  and  Microscopical 
Character,  and  of  the  chief  Diagnostic  Features,  of  the  more  important  Forms 
of  Cerebral  Tiunour :  Scrofulomata,  Syphilomata,  Gliomata,  Sarcomata, 
Carcinomata — Rare  and  unimportant  Forms  of  Tumour,         .  .  .         199 

CHAPTEE    X. 

PROGNOSIS DURATION,    COURSE,    AND    TERMINATION TREATMENT. 

Raritv  of  Cure — Causes  of  Death — Treatment — Curative  by  Drugs — Use  of  Iodide 
of  Potassium,  Mercury,  SarsaparUla,  Iodoform  Inunction,  Arsenic,  &c. — 
Operative  Treatment  —  The  Conditions  necessary  for  successful  Operative 
Interference — PaUiative  Measm-es — The  Relief  of  Pain,  Spasm,  and  Con- 
vulsions— the  Treatment  of  Apoplectic  and  Pseudo- Apoplectic  Attacks,  and 
of  Paralysis,  Optic  Neuritis,  Bed-Sores,  Cystitis,  Complica.tions,  and  Asso- 
ciated Lesions,  ,  .  .  .  .  .  .  .244 


CHAPTEE    XE 

THE    SURGICAL    TREATMENT    OF    INTRACRANIAL    TUMOURS. 
BT   A.    W.    HARE,    M.B.,    F.R.C.S.E. 

Limits  of  Sirrgical  Interference  —  Cranio-Cerebral  Localisation — Localisation   of 

Fissures — Cranio-Cerebral  Topography — Method  of  operating,  .  .         254 


LIST  OF  ILLUSTEATIONS. 


1.  Sarcoma  destroying  Motor  Cortex  ;  no  Paralysis, 

2.  Do.  do.  do. 

3.  Do.  do.  do. 

4.  Do.  do.  do. 

5.  Sarcoma  of  the  Eight  Frontal  Lobe, 

6.  Glio-Sarcoma  causing  enlargement  of  the  Left  Hemisphere, 

7.  Secondary  Cancer  of  the  Cerebellum, 

8.  Melanotic  Sarcoma  of  the  Cerebellum, 

9.  The  Normal  Fundus  Oculi,    .... 

10.  The  Fundus  Oculi  in  Optic  Neuritis, 

11.  Do.  do.  ... 

12.  Optic  Neuritis  (Microscopic  Section), 

13.  Hffimorrhage  into  Optic  Nerve  Sheath  (Microscopic), 

14.  Diagram  of  the  Motor  Tract, 

15.  Diagram  of  Lesions  in  the  Pons  Varolii  causing  Paralysis, 

16.  The  position  of  the  Motor  Centres  (Farrier), 

17.  Do.  do.  (do.) 

18.  Do.  do.  (Horsley  and  Schafer), 

19.  Lesion  causing  "  Jacksonian  "  Epilepsy, 

20.  Lesion  of  the  !Monkey's  Brain  causing  Ansesthesia  (Ferrier), 

21.  Peripheral  Constriction  of  the  Fields  of  Vision  in  Cerebral  Syphilis. 

22.  Do.  do.  do. 

23.  Homonymous  Hemianopsia  from  a  Lesion  of  the  Occipital  Lobe, 

24.  Do.  do.  associated  with  Hemiplegia, 

25.  Do.  do.  do.  do. 

26.  Scheme  of  the  Optic  Tracts  and  Visual  Centres  (Ferrier), 

27.  Temporal  Hemianopsia  (Berry),  .... 

28.  Do.  ..... 

29.  Nasal  Hemianopsia,  ..... 

30.  Lesion  of  the  Monkey's  Brain  causing  Deafness  (Ferrier), 
31  -  32.   Lesions  of  the  Monkey's  Brain  causing  loss  of  Taste  and  Smell  (Ferrier) 

33.  DiflFused  Melanotic  Sarcoma  of  the  Brain, 

34.  Do.  do.  ... 

35.  Do.  do.  (^licroscopic  Section), 

36.  Do.  do.  (do.) 

37.  Do.  do.  (do.) 

38.  Do.  do.  (do.) 


LIST  OF  ILL  USTRA  TIONS. 

FIG. 

39.  Position  of  the  Lesion  in  different  forms  of  Aphasia  (Bernard), 

40.  Dilated  Vessels  from  a  Grlioma  (Microscopic), 

41.  Do.  do.  (do.) 

42.  Aneurismal  Dila.tation  of  Vessels  in  Glioma  (do.), 

43.  Sphygmographic  Tracing,  showing  High  Tension, 

44.  Fundus  Oculi,  showing  Albuminuric  Retinitis, 

45.  Skull-Cap  in  Scrofulous  Tumour  of  the  Cerebellum, 

46.  Skidl-Cap  in  Hydatid  Tumour  of  the  Cerebellum, 

47.  Glio-Sarcoma  of  the  Frontal  Lobes,    .  .  . 

48.  Glioma  of  the  Right  Frontal  Lobe,    . 

49.  Base  of  the  Brain  showing  a  Tumour  of  the  Pituitary  Body, 

50.  Section  of  the  Brain  showing  a  Tumour  of  the  Pituitary  Body, 

51.  Base  of  the  Brain  showing  a  large  Aneurism, 

52.  Brain  showing  a  large  Aneurism  from  above, 

53.  Transverse  Section  through  the  Brain  showing  a  large  Aneurism, 

54.  Depression  in  the  Frontal  Lobes  produced  by  the  pressure  of  an  Aneurism, 

55.  Very  large  Intracranial  Aneurism,      .... 

56.  Destruction  of  the  Lenticular  Nucleus  by  a  Cancerous  Nodule, 

57.  Diagram  of  Lesions  in  the  Pons  Varolii  causing  Paralysis,    . 

58.  Facial  appearance  in  Ophthalmoplegia  Externa  Acuta, 

59.  The  same  after  recovery,         ..... 

60.  The  Third  Nerve  Nucleus  in  the  Dog  (Hensen  and  Volckers), 

61.  Diagram  of  the  Third  Nerve  Nucleus  in  Man, 

62.  Diagram  of  Lesions  in  the  Pons  Varolii  causing  Paralysis,    . 

63.  Melanotic  Sarcoma  in  the  Pons  Varolii, 

64.  Tubercular  Tumour  in  the  Pons  Varolii, 

65.  Sarcoma  of  the  Dura  Mater,  .... 
Q^.   Indentation  in  the  Cerebellum  produced  by  the  pressure  of  a  Tumour, 

67.  Compression  of  the  Veins  of  Galen  by  a  Cerebellar  Tumour  (S.  Mackenzie), 

68.  Production  of  Dropsy  of  the  Ventricles  by  a  Cerebellar  Tumoiir     (do.) 

69.  Perforating  Sarcoma  of  the  Dura  Mater  (Drummond), 

70.  Do.  do.  (do.) 

71.  Do.  do.  (do.) 

72.  Scrofulous  Enlargement  of  the  Finger, 

73.  Scrofulous  Tumour  of  the  Cerebellum, 

74.  Giant  Cells  from  a  Scrofulous  Tumour  (Microscopic), 

75.  Section  through  a  Scrofulous  Tumour  of  the  Pons  (do.) 
7  6.  Syphilitic  Gumma  on  the  Surface  of  the  Brain, 

77.  Section  through  a  Syphilitic  Gumma  of  the  Brain  (Microscopic), 

78.  Do.  do.  (do.) 

79.  Section  through  a  Syphilitic  Gumma  of  the  Pons  (do.) 

80.  Spider  Cells  from  a  Syphilitic  Gumma  (do.) 

81.  Extensive  Cerebral  Softening  due  to  Syphilis, 

82.  Do.  do.  . 

83.  Do.  do.  . 


XIV 
FIG. 

84. 
85. 
86. 
87. 
88. 
89. 
90. 
91. 
92. 
93. 
94. 
95. 
96. 
97- 

104. 
105. 
106. 
107. 
108. 
109. 
110. 
111. 
112. 
113. 
114. 
115. 
116. 


LIST  OF  ILLUSTRATIONS. 

Syphilitic  Disease  of  the  Cerebral  Vessels  (Microscopic), 

Do.  (1„.  (do.) 

Syphilitic  Neuritis  of  the  Third  Nerve  (Microscopic), 
Glioma  of  the  Brain  (Microscopic),    . 

Do.  (do.) 

Do.  (do.) 


Myxomatous  Degeneration  of  a  Sarcoma  (Microscopic), 

Do.  do.  (do.) 

Hyaloid  Degeneration  of  a  Glioma  (do. ) 

Do.  (do.) 

Spindle-Celled  Sarcoma  (Microscopic),  .  .    - 

Myeloid  Sarcoma  (do.) 

103.  A  Series  of  Transverse  Vertical  Sections  through  the 

Melanotic  Sarcoma, 
Section  through  a  Melanotic  Sarcoma  (Microscopic), 
Cells  from  a  Melanotic  Sarcoma  (do.) 

Section  through  a  Melanotic  Sarcoma  (do.) 

Deposit  of  Secondary  Cancer  on  the  Surface  of  the  Brain, 
Section  of  a  Plexiform  Angio-Sarcoma  (Microscopic), 
Do.     .  (do.) 

Do.  (do. ) 

Endothelioma  of  the  Brain,    .... 

Do.  do.  (Microscopic), 

Section  through  the  Cerebellum,  showing  a  Cured  Tumour, 
Wilson's  Cyrtometer,  .... 

Do.  in  situ, 

Head,  Skull,  and  Cerebral  Fissures  (Marshall), 


PAGE 

218 
219 
220 
223 
224 
225 


226 
227 
228 
229 
231 
232 
Brain  affected  vnth 

233-235 
236 
237 
237 
238 
239 
240 
241 
242 
242 
245 
259 
260 
262 


INTRACRANIAL    TUMOURS. 


INTRACRANIAL    TUMOURS. 


CHAPTER   I. 

DEFINITION  —  INTEODUCTION  —  ETIOLOGY  —  GENEEAL 
PATHOLOGY  AND  PATHOLOGICAL  PHYSIOLOGY. 

Definition. — Under  the  term  intracranial  tumour,  it  is  customary 
to  include  all  new  growths  which  originate  within,  or  are  contained 
in,  the  cavity  of  the  cranium. 

Localised  inflammatory  thickenings  or  deposits,  more  especially 
when  syphilitic  and  tubercular,  are,  in  some  cases,  with  difficulty 
distinguished  from  the  more  sharply  defined  new  growths — tumours 
properly  so  called  ;  indeed  the  distinction  may  be  impossible,  for 
the  two  conditions  are  often  combined,  and  may  insensibly  run  one 
into  the  other. 

Cerebral  abscesses  are  not  included  under  the  definition;  for, 
although  in  some  cases  it  may  be  difficult  or  impossible  to  differentiate 
a  chronic  abscess  from  a  cerebral  tumour  during  life,  the  distinction 
is  readily  enough  made  post  mortem. 

Large  aneurisms  and  parasitic  cysts  must  be  regarded  as  intra- 
cranial tumours. 

Simple  cysts,  as  well  as  cysts  which  develop  in  connection  with 
gliomata  and  other  forms  of  new  growth,  are  usually  described  in 
connection  with  intracranial  tumours. 

Introduction. — The  subject  of  intracranial  tumours  is  of  great 
interest,  from  a  clinical,  physiological,  and  pathological  point  of  view. 

A 


2  INTRODUCTION. 

The  brain  and  its  membranes  are  favourite  situations  for  the 
formation  of  new  growtlis.  In  no  other  situation  in  the  body  is  such 
a  great  variety  of  tumours  met  with ;  it  would  almost  indeed 
seem  that  the  delicate  and  soft  brain  tissue,  richly  supplied  as  it  is 
with  blood-vessels  and  lymphatics,  is  as  fine  a  forcing  and  feeding 
ground  for  new  growths  as  Koch's  nutrient  jelly  is  for  micrococci 
and  allied  organisms.  Syphilitic  and  tubercular  tumours,  gliomata, 
and  the  various  forms  of  sarcoma,  are  most  frequently  met  with ; 
different  varieties  of  cancer,  endotheliomata  (cylindromata),  and 
psammomata  are  not  uncommon  ;  while  cholesteatomata,  parasitic 
cysts  (Ecliinococci  and  Cysticercus  Celhtloscc),  melanomata,  osteomata, 
fibromata,  lipomata,  and  neuromata  are  more  rare. 

N"ew  growths  may  occur  in  any  part  of  the  intracranial  cavity. 
In  some  cases  the  tumour  is  single,  in  others  multiple.  The  tumour 
may  derange  the  functions  of  the  great  intracranial  nerve  centres  as 
a  whole ;  or  it  may  invade,  and  irritate  or  destroy,  individual 
parts — limited  portions  of  grey  matter,  conducting  tracts,  or  peri- 
pheral (cranial)  nerves.  The  symptoms  are  in  some  cases  of  the 
most  diverse  and  complicated  character ;  and  the  diagnosis  may  be 
attended  with  great  difficulty.  But  in  no  disease  is  an  exact 
diagnosis  of  more  importance  ;  for,  while  experience  has  abundantly 
shown  that  it  is  impossible  to  cure  intracranial  tumours  (the 
syphilitic  variety  in  many  cases  excepted)  by  any  internal  remedies 
with  which  we  are  at  present  acquainted,  the  results  obtained  by 
Hughes  Bennett,  Godlee,  and  Victor  Horsley  go  far  to  prove  that  in 
some  cases  at  all  events  intracranial  tumours  may  be  satisfactorily 
removed  by  operation.  But  since  the  removal  of  the  new  growth 
is  in  many  instances  altogether  impossible,  a  correct  diagnosis  is 
obviously  essential  for  successful  interference.  The  exact  localisation 
of  the  tumour  is  necessarily  a  point  of  the  first  importance  ;  while  a 
knowledge  of  the  pathological  character  of  the  new  growth  may 
enable  us  to  decide  whether  an  operation  is  feasible  or  not. 

Etiology. — The  causation  of  intracranial  tumours  differs  in  no 
way,  so  far  as  I  know,  from  the  causation  of  tumours  in  other  parts 
of  the  body. 

In  some  cases  the  new  growth  is  primary,  in  others  secondary ;  in 


E TIOL OGY:  EFFE CTS  OF  INJUR  V.  3 

the  latter,  the  primary  tumour  may  be  situated  in  any  part  of  the 
body,  but  secondary  deposits  of  new  growth  in  the  intracranial  nerve 
centres  are,  I  think,  especially  apt  to  follow  similar  diseased  conditions 
of  the  pulmonary  tissue.  This  is  probably  due  to  the  fact  that 
when  the  primary  new  growth  is  situated  elsewhere,  say  in  the 
abdomen,  the  liver  and  the  lung  act  as  filters,  and  protect  the  brain, 
catching  as  it  were  any  minute  particles  of  malignant  growth  which 
get  into  the  venous  circulation ;  whereas,  when  the  lungs  are  them- 
selves the  seat  of  the  disease,  any  infective  particles  which  get  into 
the  circulation,  are  carried  to  the  left  heart,  and  may  consequently 
find  their  way,  through  the  arterial  system,  to  the  brain  as  well  as  to 
the  other  organs.  This  explanation  of  course  applies  only  to  those 
cases  in  which  the  secondary  deposits  are  carried  to  the  brain  through 
the  blood-vessels. 

It  is  unnecessary  to  say  anything  with  regard  to  the  hereditary  and 
general  constitutional  causes  which  predispose  to  tumour  formation. 

Amongst  the  more  direct  causes,  injury  occupies  an  important 
place.  There  can,  I  think,  be  little  doubt  that  blows  and  falls  on  the 
head  do  sometimes  lead  to  the  formation  of  gliomatous,  and  perhaps 
also  of  sarcomatous  tumours ;  syphilitic  tumours,  too,  not  infrequently 
appear  to  owe  their  exciting  cause  to  a  head  injury;  and  in  two 
instances  I  have  known  a  scrofulous  tumour  to  follow  a  severe  blow 
upon  the  head,  the  new  growth  developing  either  immediately  below 
the  seat  of  the  injury,  or  at  the  point  of  contre-coup.  The  explana- 
tion of  such  cases  is  probably  this,  that  the  blow  produces  a  local 
inflammatory  lesion  or  contusion,  which  forms  a  suitable  nidus  for 
the  development  of  the  tubercular  germs  (tubercle  bacillus  or  its 
spores)  which  are  already  circulating  through  the  system. 

How  far  mental  anxiety  and  worry,  or  other  conditions  which 
depress  and  exhaust  the  cerebral  nerve  centres,  and  how  far  alcoholic 
excesses  and  other  conditions  which  are  attended  with  repeated 
cerebral  congestions,  may  predispose  to,  or  aid  in,  the  formation 
of  brain  tumours,  is  altogether  uncertain.  Whether,  too,  any  of 
the  new  growths  which  occur  within  the  cavity  of  the  cranium 
owe  their  origin  to  micro-organisms  is  unknown  ;  but  I  have  for 
long  thought  it  probable  that  the  cause  of  some  forms  of  glioma 
is  of  this  nature. 


4  ETIOLOGY. 

Intracranial  tumours  are  more  Irequent  in  the  male  than  in  the 
female  ;  in  some  cases  this  is  doubtless  due  to  the  fact  that  men 
are  more  frequently  affected  with  syphilis,  and  are  more  exposed  to 
head  injuries,  and  possibly  because  they  are  more  addicted  to  alcoholic 
excesses  than  women. 

For  the  same  reason,  those  persons  whose  occupation  exposes 
them  to  head  injuries,  and  possibly  to  mental  worry  and  anxiety,  are 
perhaps  somewhat  more  liable  to  be  affected  with  intracranial  tumours 
than  other  members  of  the  community.  Occupation  is,  however,  a 
matter  of  very  little  consequence  from  an  etiological  point  of  view. 

Age  is  of  more  importance,  for  undoubtedly  some  forms  of  tumour 
are  more  likely  to  appear  at  one  age  than  at  another.  Scrofulous 
tumours  are  more  common  in  the  young  ;  syphilitic  tumours  in 
adults,  the  period  of  greatest  frequency  being  probably  between  the 
ages  of  thirty  and  forty-five ;  cancers  of  the  brain,  like  cancers  else- 
where, are  more  common  in  old  people ;  gliomatous  tumours  may 
occur  at  any  age,  but  in  my  experience  are  more  frequently  seen  in 
young  persons  or  in  adults — i.e.,  not  in  old  people. 

The,  general  'pathology  and  pathological 'physiology  ofhrain  tumours. 
— The  number  of  symptoms  which  may  be  produced  by  intracranial 
tumours  is  very  great,  and  the  manner  in  whicli  they  may  be 
grouped  and  arranged  most  diverse.  Hence  the  clinical  picture  which 
individual  cases  present  may  be  very  different.  Now,  since  the  exact 
nature  of  the  symptoms  wliich  are  present  in  any  given  individual 
case  depends  upon  the  effects  which  the  new  growth  has  upon  {a) 
the  intracranial  contents,  and  (J)  the  cranial  walls,  it  follows  that 
the  intelligent  comprehension  of  this  difficult  part  of  the  subject 
will  be  greatly  facilitated  if  we  start  with  clear  notions  as  to  the 
effects  which  intracranial  tumours  in  general  may  produce  upon  the 
brain  and  other  structures  contained  within  the  cavity  of  the  cranium. 

In  the  first  place,  it  is  essential  to  remember  that,  after  the  sutures 
have  been  ossified,  the  cavity  of  the  cranium  is,  for  all  practical 
purposes,  a  closed  cavity ;  and  that,  when  a  tumour  or  new  growth 
is  developed  in  any  part  of  it,  the  intracranial  pressure  must  neces- 
sarily be  increased,  and  the  brain,  and  other  structures  contained 
within  it,  must  necessarily  be  compressed,  unless   compensation  is 


GENERAL  PATHOLOGY.  5 

effected,  and  increased  pressure  and  squeezing  prevented,  either 
by  atrophy  of  intracranial  structures,  displacement  of  intracranial 
fluids,  or  yielding  of  cranial  walls,  i.e.,  separation  of  the  sutures. 

Further,  it  must  be  remembered  that  the  general  cavity  of  the 
cranium  is  divided  by  the  tentorium  cerebelli  into  two  separate  parts ; 
and  that  while  tumours  growing  above  the  tentorium  chiefly  compress 
the  parts  which  are  situated  in  the  upper  cranial  cavity,  and  as  a 
rule  exert  comparatively  little  pressure  upon  the  cerebellum, 
pons  Varolii,  and  medulla  oblongata  {i.e.,  the  parts  in  the  lower 
cavity),  the  reverse  is  by  no  means  the  case.  Subtentorial  tumours, 
in  fact,  may  not  only  exert  very  great  compression  on  the  parts  in 
their  immediate  neighbourhood  (cerebellum,  pons  Varolii,  and  medulla 
oblongata),  but  may,  and  very  frequently  do,  by  producing  dropsy  of 
the  ventricles,  cause  an  enormous  increase  of  pressure  in  the  upper 
cavity,  or,  as  we  may  term  it,  the  cavity  of  the  brain  proper.  Nay, 
further,  a  small  tumour  or  cicatricial  inflammatory  product,  which 
produces  comparatively  little  direct  (pressure)  effects  upon  the  parts 
below  the  tentorium  {i.e.,  in  its  immediate  neighbourhood),  may  cause 
great  distention  of  the  ventricles  and  enormous  increase  of  the  general 
intracranial  pressure. 

In  a  less  perfect  manner,  the  upper  cranial  cavity  is  divided  by 
the  falx  into  two  separate  cavities ;  and  by  means  of  the  resistance 
which  this  tough,  partitioning  membrane  affords,  the  cerebral  hemi- 
sphere on  one  side  is  to  some  extent  protected  from  the  pressure 
effects  of  a  large,  rapidly  increasing  tumour  on  the  other. 

As  a  matter  of  fact,  flattening  of  the  convolutions,  obliteration  of 
the  sulci,  ansemia  of  the  surface  of  the  brain,  a  dry,  sticky  condition 
of  the  membranes,  and  in  many  instances  dropsical  distention  of  the 
ventricles  with  oedema  of  the  brain  tissue — in  other  words,  the  post 
mortem  evidences  of  increased  intracranial  pressure — are  met  with 
in  the  great  majority  of  cases  of  intracranial  tumour  after  death  ; 
and  it  is,  I  believe,  to  this  increased  intracranial  pressure  and  its 
results  that  the  general  symptoms  of  intracranial  tumour,  such  as 
headache,  vomiting,  double  optic  neuritis,  vertigo,  mental  dulness, 
lethargy,  &c.,  are  largely  due. 

The  exact  causation  of  the  double  optic  neuritis  is  a  matter 
of  dispute.     Personally  I  am  of  opinion  that  increased  intracranial 


6  GENERAL  PA  THOL  OGY. 

pressure  is  in  many  cases  an  important,  though  not  the  sole  or  perhaps 
the  most  important,  factor  in  its  production.  This  point  will  afterwards 
be  considered  more  in  detail. 

The  term  gcnercd  is  here  used  to  indicate  those  symptoms  which 
result  from  the  presence  of  a  tumour  in  any  part  of  the  cranial  cavity, 
as  distinct  from  the  localising  symptoms,  which  are  due  to  the  effects 
which  the  tumour  produces  on  special  parts,  and  which  are  indicative 
of  its  exact  locality  or  seat. 

As  we  shall  afterwards  see,  headache,  when  localised — and  more 
especially  when  associated  with  tenderness  on  skull  percussion — 
vomiting  and  vertigo,  when  obstinate  and  severe,  may  have  a  localis- 
ing value  ;  but  in  most  instances  these  symptoms  are  general  rather 
than  localising  symptoms,  and  cannot  be  taken  as  guides  to  the  posi- 
tion of  the  new  growth. 

Now  the  degree  of  the  increase  of  the  intracranial  pressure  and 
the  extent  of  the  compression  to  which  the  intracranial  contents  are 
subjected,  depend  upon  {a)  the  size,  and  (b)  the  rajjidity  of  the  growth 
of  the  tumour ;  together  with  (c)  the  presence  or  absence  of  dropsical 
distention  of  the  ventricles  and  the  extent  thereof. 

In  the  case  of  tumours  which  grow  ra^^idly  and  are  of  large  size — 
which,  in  other  words,  are  attended  with  great  increase  of  the  intra- 
cranial pressure — we  should  expect  the  general  symptoms  of  tumour 
(headache,  vomiting,  double  optic  neuritis,  &c.)  to  be  well  marked; 
and  such  in  fact  is  usually  the  case.  Towards  the  later  periods  of 
cases  of  this  description,  and  in  many  cases  in  which  there  is 
dropsy  of  the  ventricles,  the  headache  and  other  s}Tnptoms,  which 
in  the  earlier  stages  may  have  been  well-marked  and  characteris- 
tic, often  become  less  prominent,  or  may  altogether  disappear, 
in  consequence  probably  of  the  fact  that,  owing  to  the  aniemia, 
oedema,  and  compression  of  the  nervous  tissue,  the  sensibility  of 
the  brain  is  diminished,  the  feelings  and  perceptions  are  dulled, 
and  a  condition  of  hebetude,  mental  apathy,  semi-coma,  or  actual 
coma,  is  produced. 

In  those  cases,  on  the  contrary,  in  which  the  tumour  is  of  small 
size  or  of  slow  growth ;  in  cases  in  which,  as  the  tumour  grows,  the 
brain  tissue  atrophies ;  in  cases  in  which  the  fontanelles  are  not  yet 
closed,  and  yielding  of  the  bones  of  the  skull  readily  takes  place :  in 


IRRITATIVE  LESIONS.  7 

other  words,  in  those  cases  in  which  there  is  little  or  no  increase  of 
the  intracranial  pressure,  the  general  symptoms  of  tumour  may  be 
altogether  absent  or  little  marked. 

Another  factor  which  probably  plays  an  important  part  in  the 
production  of  the  "  general "  symptoms  is  the  "  irritation "  which 
the  tumour  produces  in  the  nervous  tissues  and  in  the  cerebral 
membranes. 

In  some  cases  of  intracranial  tumour,  as  I  shall  afterwards  point 
out,  a  diffused  irritative  change — which  causes  enlargement  of  the 
nervous  tissues  surrounding  the  tumour,  and  is  chiefly  characterised 
on  microscopical  examination  by  increased  size  of  the  connective 
tissue  corpuscles  or  Deiter's  cells — is  found  throughout  the  brain 
tissue ;  but  more  especially  in  the  hemisphere  or  part  of  the  brain  in 
■which  the  tumour  is  situated. 

In  some  cases  the  membranes  seem  to  be  involved  in  this  process 
of  irritation,  and  there  is  distinct  naked-eye  evidence  of  thickening 
and  chronic  meningitis.  In  others,  in  which  no  such  naked-eye 
appearances  are  to  be  seen,  it  is  said  that  inflammatory  changes  in 
the  meninges  can  be  demonstrated  by  means  of  the  microscope.  I 
cannot  say  that  I  have  been  able  to  satisfy  myself  with  regard  to  this 
point.  In  many  of  the  cases  of  intracranial  tumour  which  have 
come  under  my  notice  there  have  been  no  distinctive  naked-eye 
appearances  of  diffused  meningitis ;  while  in  the  great  majority  the 
usual  post-mortem  signs  of  increased  intracranial  pressure  have  been 
prominent.  In  the  cases  of  this  kind  which  I  have  subjected  to 
careful  microscopical  examination,  I  have  failed  to  find  distinctive 
evidence  of  meningitis ;  but  I  have  in  most  cases  detected  en- 
largement of  the  connective  tissue  corpuscles,  and  evidences  of 
irritative  chancjes  in  the  brain  tissue  surrouudino-  the  tumour.  In 
some  cases,  I  have  satisfied  myself  that  these  irritative  changes 
were  wide-spread. 

What  share  this  diffuse  irritative  change  in  the  neighbourhood 
of  the  tumour  may  take  in  the  production  of  the  general  symptoms 
(headache,  vomiting,  double  optic  neuritis,  &c.),  I  am  not  prepared  to 
say.  That  it  has  some  influence  is  probable;  but,  so  far  as  I  can 
judge,  it  is  not  such  an  important  factor  as  meningeal  irritation  and 
increased  intracranial  pressure. 


8  GENERAL  PATHOLOGY. 

In  the  second  place,  the  new  growth  necessarily  presses  upon  or 
involves  special  structures  and  parts ;  and  it  is  to  the  derangements 
which  are  produced  in  the  structures,  which  are  thus  pressed  upon  or 
involved,  that  another  great  and  most  important  group  of  symptoms 
— the  localising  symptoms,  as  they  are  termed — is  due. 

The  exact  nature  of  the  localising  symptoms  depends  upon  the 
following  points : — 

(1.)  Tlie  function  of  the  particular  part  of  the  cerebrum,  cere- 
bellum, pons,  medulla,  intracranial  nerves,  blood-vessels,  membranes, 
bones,  &c.,  which  is  pressed  upon  or  involved. 

This  point  is  self-evident,  and  needs  no  amplification.  It  is  quite 
obvious  that  in  a  case  in  which  the  tumour  is  situated  in  the  neigh- 
bourhood of  the  fissure  of  Eolando,  and  in  which  the  motor  centres 
are  pressed  upon  or  involved,  the  symptoms  will  be  quite  different 
from  a  case  in  which  the  tumour  involves  the  prefrontal  or  occipital 
lobes ;  and  that  the  exact  character  of  the  paralyses  or  spasms,  which 
are  present  in  the  former  case,  will  depend  upon  the  exact  portion  of 
the  motor  area  which  happens  to  be  affected. 

(2.)  The  manner  in  which  the  part  which  is  pressed  upon  or 
involved  by  the  tumour  is  affected — whether  irritated  or  destroyed — 
and,  more  especially  in  the  case  of  destroying  lesions,  the  extent  of 
the  changes  which  are  induced  in  it. 

Speaking  generally,  it  may  be  stated  that  the  effect  of  all  lesions 
on  the  nervous  tissues  is  to  produce  one  or  other  of  two  results,  viz., 
either  diminution  or  abolition  of  function  on  the  one  hand,  or  increase 
of  function  on  the  other.  It  must,  however,  be  remembered  that  the 
increased  function,  which  results  from  pathological  causes,  is  seldom 
a  simple  increase  ;  as  a  rule,  the  function  is  not  only  increased,  but  is 
also  perverted  in  character.  Paralysis,  anaesthesia,  and  dementia  are 
good  examples  of  diminished  or  abolished  function  ;  convulsions, 
neuralgia,  and  mania  of  increased  and  perverted  function. 

In  some  cases  in  which  the  symptoms  are  indicative  of  increased 
function,  the  primary  lesion  is  probably,  as  Dr.  Hughlings  Jackson 
has  suggested,  a  "destroying"  one,  i.e.,  a  lesion  which  produces 
diminution  or  destruction  of  function.  It  would  appear,  for  example, 
that  in  some  cases  of  mania  the  highest  and  most  specialised  parts  of 
the  cerebral  nerve  apparatus  are  put  hors  dc  combed,  with  the  result 


IRRITATIVE  AND  DESTRUCTIVE  lESIONS.  9 

that  the  lower  cerebral  centres  are  not  restrained  as  they  are  in 
health,  the  net  result  being  symptoms  of  a  maniacal  character.  In 
cases  of  this  description,  Dr.  Hughlings  Jackson  supposes  that  the 
increased  function  is  apparent  only,  and  that  the  increase  is  in  reality 
due  to  the  fact  that  the  function  of  the  highest  (controlling)  centres 
is  destroyed,  diminished,  or  temporarily  suspended  by  the  lesion. 

Now,  whether  a  tumour  which  is  pressing  upon  or  involving  a 
portion  of  brain  tissue  will  produce  diminution  or  exaltation  of 
function,  would  appear  to  be  due  to  {a)  the  rapidity  with  which  it  is 
growing ;  (b)  its  pathological  nature ;  and  (c)  the  composition,  so  to 
speak,  of  the  nerve  tissue  with  which  it  is  in  contact,  i.e.,  whether 
grey  or  white  matter.  Whether  the  pressure  is  continuous  or  inter- 
mittent is  doubtless  also  a  factor  of  importance.  Other  things  being 
equal,  a  rapidly  growing  tumour  is  more  likely  to  produce  irritation 
of  nerve  tissue,  and  particularly  of  grey  nerve  tissue,  than  a  slow 
growing  one ;  while  a  tumour  of  slow  development  is  much  more 
likely  to  produce  a  simple  atrophy  of  the  tissue  on  which  it  presses. 

Further,  as  we  shall  afterwards  see,  irritation  of  grey  matter  of 
necessity  gives  rise  to  symptoms — granting  of  course  that  the  irrita- 
tion is  sufficiently  great  to  excite  discharge,  and  that  the  way  out  for 
the  nerve  force  is  not  obstructed — while  destruction  of  grey  matter  is 
frequently  compensated  and  unattended  by  any  external  manifesta- 
tions. Again,  as  we  have  already  seen,  a  rapidly  growing  tumour  is 
more  likely  to  produce  increased  intracranial  pressure  and  diffuse 
irritative  changes  than  a  slow  growing  one.  For  all  these  reasons, 
then,  a  tumour  of  rapid  development  is  more  frequently  attended  by 
symptoms  both  general  and  localising  than  a  tumour  of  slow  growth. 

The  pathological  nature  of  the  tumour  is  also  of  great  importance 
in  determining  whether  irritation  or  destruction  will  result  in  the 
nerve  tissue  which  is  implicated. 

Those  tumours  which  are  surrounded  by  a  capsule,  which  do  not 
infiltrate  the  tissues  with  which  they  come  in  contact,  and  wliich 
have  little  or  no  tendency  to  produce  meningitis  (such  as  fibrous, 
fatty,  and  cystic  tumours,  some  sarcomata,  &c.),  are  much  less  likely 
to  produce  irritation  than  those  new  growths  (such  as  gliomatous, 
syphilitic,  tubercular,  cancerous  tumours,  and  some  varieties  of 
sarcoma)  which  produce  the  opposite  effects — i.e.,  which  do  infiltrate 


lo  GENERAL  PATHOLOGY. 

the  structures  with  which  tliey  come  in  contact,  or  which  have  a 
strong  tendency  to  produce  cerebritis  or  meningitis. 

Encapsuled  tumours  are  as  a  rule  of  slow  growth,  but  infiltrating 
tumours,  thougli  they  usually  develop  rapidly,  do  not  always  do  so. 
I  have,  with  Dr.  Leslie,  reported  a  case  of  infiltrating  glioma  in 
which  the  duration  was  certainly  five  years ;  and  another  case  of  the 
same  kind,  in  which  the  duration  was  perhaps  even  longer.  ^ 

But  whether  symptoms  will  result  from  the  irritative  or  destruc- 
tive changes  which  a  tumour  produces  in  the  nerve  tissue  on  which  it 
presses,  or  through  which  it  infiltrates,  depends  to  a  large  extent  upon 
the  fact  whether  that  nerve  tissue  is  composed  of  grey  or  white 
matter.  For  it  is  important  to  remember,  on  the  one  hand,  that 
discharge  of  nervous  energy  is  much  more  readily  produced  by  irrita- 
tation  of  nerve  cells  than  of  nerve  tubes  ;  tumours  which  are  situated 
on  the  surface  of  the  brain  (such  as  tubercular  and  syphilitic 
deposits),  and  which  involve  and  irritate  the  grey  matter,  are 
tlierefore  much  more  likely  to  be  attended  with  "  irritative  s}-inp- 
toms  "  (spasms,  flashes  of  light,  &c.),  than  tumours  which  involve  and 
irritate  nerve  tubes,  say  in  the  centrum  ovale,  internal  capsule,  or 
peripheral  nerves. 

On  the  other  hand,  destruction  of  grey  matter  is  much  more  easily 
compensated  than  destruction  of  conducting  fibres  or  nerve  tubes. 
Destruction  of  a  part  of  the  motor  cortex,  indeed  of  a  very  large  part, 
as  the  specimen  represented  in  Figs.  1,  2,  3,  and  4  shows,  may  be  quite 
unattended  with  symptoms  {i.e.,  paralysis),  but  a  limited  destruction 
of  the  conducting  fibres,  say  of  the  internal  capsule,  is,  as  far  as  we 
know,  almost  certain  to  be  followed  by  paralysis. 

Whether  permanent  paralysis  will  result  from  destruction  of 
motor-conducting  fibres  is  also  largely  dependent  upon  the  degree  of 
specialisation,  so  to  speak,  of  the  movements  with  which  those  fibres 
are  concerned.  Destruction  of  the  fibres  which  innervate  the  muscles 
of  the  thumb  and  fingers  will  produce  more  lasting  and  permanent 
paralysis  than  destruction  of  the  fibres  which  supply  the  muscles  of  the 
upper  arm  and  shoulder.  For  the  same  reason,  as  will  be  afterwards 
more  fully  explained,  compensation  is  more  readily  effected  in  the 
lower  than  in  the  upper  extremity,  for  the  movements  of  the  leg  are 

*  Ed'iiiburjh  Medical  Journal,  January  1SS7,  pp.  591  and  623. 


DESTRUCTION  OF  MOTOR  CENTRES.  ii 

more  automatic  (less  highly  specialised  and  less  independent  of  those 
of  the  opposite  leg)  than  the  movements  of  the  arms. 

The  effects  of  "  destroying  "  and  "  discharging "  lesions,  and  the 
important  subject  of  "  compensation,"  will  be  afterwards  considered 
more  in  detail. 

In  considering  the  local  alterations  which  the  tumour  produces  in 

T 


Fig.  1. — Diagrammatic  outline  of  the  right  hemisphere  of  the  brain  in 
the  case  of  M.  D.,  showing  the  exact  position  of  the  lesion  (the  dark  area  to 
which  the  letter  T  points). 

The  letter  F  points  to  the  frontal  and  0  to  the  occipital  end  of  the  brain  ; 
R  to  the  fissure  of  Eolando,  and  B  to  the  fissure  of  Sylvius  ;  T  to  the  tumour. 

The  patient,  a  girl,  aged  twenty,  was  admitted  to  the  Newcastle-on- 
Tyne  Infirmary  under  my  care  on  February  5th,  1S77,  suSering  from 
headache,  vomiting,  and  giddiness.  There  was  weU- marked  double  optic 
neuritis,  but  absolutely  no  paralysis.  Under  iodide  of  potassium  great  im- 
provement took  place,  and  the  patient  felt  so  well  that  she  had  made  arrange- 
ments to  leave  the  hospital.  The  very  night  before  she  was  to  go  home, 
she  was  seized  with  an  epileptiform  convulsion,  in  which  she  died. 

At  the  post-mortem  examination  the  very  large  tumour,  represented  in 
Figs.  2,  3,  and  4,  was  found  ;  it  had  produced  very  extensive  destruction  of 
the  motor  centres,  and  yet  there  was  never  the  slightest  trace  of  paralysis. 

The  case  is  reported  in  full  in  the  Edinburgh  Medical  Journal  for  February 
3879,  p.  693. 

the  parts  with  which  it  is  in  direct  contact,  it  is  necessary  to  remember 
that  the  symptoms  which  result  are  not  always  directly  due  to  the 
derangement  of  function  in  the  part  which  is  immediately  implicated, 
but  that  they  may  be  the  result  of  indirect  and  secondary  alterations 
in  some  other  and  distant  part  of  the  nervous  tissue. 

The  point  is  one  of  practical  importance,  for  symptoms  produced 
in  this  way  may  be  localised  and  limited  in  extent,  and  may  give  an 
erroneous  idea  of  the  position  of  the  tumour. 

Symptoms  of  this  kind — pseudo-loccdising  symptoms,  as  they  may 


12  GENERAL  PATHOLOGY. 

perhaps  be  termed — are,  I  believe,  chiefly  produced  in  one  or  other  of 
the  following  ways. 


Fig.  2. — The  outer  surface  of  the  right  hemisphere  of  the  brain  in  the 
case  of  M.  D.  (large  sarcoma  growing  from  the  dura  mater,  which  had  pro- 
duced extensive  atrophy  of  the  motor  centres,  but  was  unattended  with 
paralysis),  showing  the  tumour  in  situ.  (Copied  from  a  photograph  and  some- 
what reduced  in  size.) 

The  letter  A  points  to  the  outer  surface  of  the  dura  mater  over  the  centre 
of  the  tumour. 


DESTRUCTION  OF  MOTOR  CENTRES. 


13 


(1.)  By  alterations  of  the  blood  vascular  suiiply  to  distant  centres 
and  parts. — A  syphilitic  gumma  at  the  base  of  the  brain,  for  example, 


B 


\ 


Fltt.  3,— The  outer  surface  of  the  right  hemisphere  of  the  brain  in  the 
case  of  M.  D.,  showing  the  brain  after  the  tumour  was  removed.  (Copied 
from  a  photograph,  and  somewhat  reduced  in  size.) 

The  letter  B  points  to  the  extensive  depression  on  the  surface  of  the 
brain,  into  which  the  tumour  fitted. 


14  GENERAL  PATHOLOGY. 

which  involves  and  destroys  the  third  nerve,  may  at  the  same  time 
surround  and  obstruct  the  middle  cerebral  artery,  and  produce  ex- 


^r    ■•>; 


i'       T 


1"        •  "^ 


A 


>^         rri 


/^^ 


\^     -       -v-^>?: 


■"^i 

i%i 

''V- 

.*"« 

1 

,       -       '"^ 

■3^          ' 

^    .:?^ 

l;^,' 

^      1 

YiG.  4. — Transverse  vertical  section  through  the  right  hemisphere  of  the 
brain  in  the  case  of  M.  D.,  showing  the  tumour  in  section,  and  the  depres- 
sion in  the  brain  tissue  produced  by  it.  (Copied  from  a  photograph,  and 
somewhat  reduced  in  size.) 

The  letter  A  points  to  the  tumour  ;  B  is  placed  on  the  inner  (left)  side  of 
the  right  hemisphere,  which  has  been  separated  from  the  opposite  (left) 
hemisphere  by  a  section  made  from  before,  backwards  in  the  middle  line. 

tensive  softening  of  the  motor  convolutions  ;  the  resulting  paralysis — 
hemiplegia  on  the  opposite,  and  paralysis  of  the  muscles  supplied  by 
the  third  nerve  on  the  same  side — is  suggestive  of  a  chronic  lesion 
of  the  crus  cerebri.  Other  illustrative  examples  might  be  given,  but 
this  point  is  so  obvious  that  further  details  are  unnecessary.  Possibly 
the  vascular  supply  of  a  distant  part  of  the  brain  tissue  may  be 
altered,  and  the  nutrition  and  function  of  that  centre  affected,  by  the 
pressure  of  a  tumour  upon  the  vaso-motor  nerves  distributed  to  the 
blood-vessels. 

(2.)  By  indirect  {reflex)  irritation  or  inhibition  of  distant  centres. 
— In  cases  of  this  description  the  tumour  produces  alterations,  struc- 
tural and  functional,  in   the  centre  with  which  it  is  immediately 


FSEUnO-LO CAUSING  SYMPTOMS.  15 

in  contact  (centre  A),  with  the  result  that  a  distant  centie  (i/)  is 
either  irritated  or  inhibited.  The  symptoms  which  are  produced  in 
this  manner  show  that  the  function  of  the  distant  centre  (B)  is 
deranged;  hence  the  observer  may  conclude  that  the  tumour  is 
situated  in  the  immediate  neighbourhood  of  that  centre. 

That  the  function  of  a  part  of  the  brain  which  is  itself  free  from 
disease  may  be  deranged  (excited  or  inhibited)  in  consequence  of 
disease  in  some  other  and  distant  part,  seems  certain.  It  is  proljable 
that  in  some  cases  of  mental  derangement  the  symptoms  are  pro- 
duced in  this  way ;  and  the  phenomena  of  certain  cases  of  aphasia 
seem  to  show  that  lesions  on  the  sensory  side  of  the  speech 
mechanism  (sensory  speech  centres)  almost  of  necessity  produce 
derangements  in  the  motor  (speech)  centres.  Possibly,  too,  the 
nervous  derangements  (paralyses,  spasms,  &c.)  which  are  met  with 
in  some  cases  of  hysteria  may  be  best  explained  in  this  manner; 
but  that  such  coarse  phenomena  as  localised  spasms  and  localised 
paralyses  are  frequently  or  usually  produced  in  this  way,  as  Brown- 
Sequard  in  particular  would  have  us  suppose,  seems  to  me  alto- 
gether improbable.  The  risk  of  erroneous  diagnosis  (localisation)  from 
this  cause  has,  in  my  opinion,  been  exaggerated.  When,  in  short,  in  a 
case  of  intracranial  tumour  the  symptoms  clearly  point  to  derange- 
ment of  function  in  a  localised  and  limited  portion  of  brain  tissue,  the 
physician  will,  1  think,  be  wise  to  give  the  fact  its  full  localis- 
ing value.  In  the  majority  of  cases  of  this  description  the  symptoms 
are  directly  due  to  deranged  function  in  the  nerve  tissue  which  is  in 
the  immediate  neighbourhood  of  the  tumour,  or  of  some  nodule  of 
new  growth  in  the  case  of  a  multiple  lesion.  Irritation  is  chiefly  pro- 
duced in  the  nervous  tissue  which  surrounds  the  tumour.  The 
irritative  phenomena,  therefore,  do  not  so  directly  point  to  the  exact 
position  of  the  new  growth  as  the  symptoms  due  to  destruction.  In 
those  cases  in  which  no  such  direct  relationship  exists,  a  sufficiently 
carefully  conducted  post-mortem  examination  (naked  eye  and  micro- 
scopic) may  be  expected  to  show  distinct  pathological  changes  in  the 
part  whose  function  was  deranged,  and,  in  some  instances  at  all  events, 
to  demonstrate  the  manner  in  which  this  apparently  independent 
lesion  had  indirectly  resulted  from  the  presence  of  the  new  growth 
— i.e.,  to  show,  for  example,  that  the  tumour  had  involved  the  vessels 


i6 


GENERAL  PATHOLOGY. 


supplying  the  affected  part,  or  that  it  had  so  altered  the  relationship 
of  the  parts  within  the  cranium  as  to  produce  localised  pressure  on 
the  affected  part,  on  the  vessels  supplying  it,  or  on  the  conducting 
tracts  proceeding  from  it,  &c. 

It  is  quite  common,  in  fact  usual,  to  find  the  hemisphere  in  which 
the  tumour  is  situated  larger  than  the  opposite  one.  In  some  cases 
this  increase  in  size  is  accounted  for  by  the  size  of  the  tumour  itself ; 
in  others  it  is  due  to  oedema  or  inflammatory  swelling  around  the 


Fig.  5. — Transverse  vertical  section  through  the  frontal  lobes  in  a  case 
of  tumour  (sarcoma)  of  the  right  hemisphere. 

The  right  frontal  lobe  in  which  the  new  growth  (to  which  the  letter  A 
points)  is  situated  is  markedly  larger  than  the  left. 

The  letter  B  points  to  that  part  of  the  left  hemisphere  which  is  situated 
just  in  front  of  the  lateral  ventricle  ;  C,  to  the  tip  of  the  left  temporo- 
sphenoidal  lobe. 

new  growth ;  but  in  many  cases  it  seems  to  be  due  to  the  chronic 
diffuse  (irritative)  change  which  has  been  previously  referred  to. 

In  consequence  of  the  swelling  which  is  produced  in  one  or  other 
of  these  ways,  the  relationship  of  the  different  parts  contained  within 
the  cranium  may  be  considerably  altered ;  and,  as  a  result  of  stretching, 
twisting,  or  squeezing,  the  functions  of  portions  of  the  nerve  tissue,  at 
a  distance  from  the  tumour,  may  be  deranged,  or  their  vascular  supply 
interfered  with. 


SYMPTOMS  DUE  TO  ASSOCIATED  LESIONS. 


17 


In  Figs.  5  and  6,  the  swollen  condition  of  the  hemisphere  in  which 
the  tumour  is  situated  is  well  shown. 


Fig.  6. — Transverse  vertical  section  through  the  brain,  showing  a  large 
glio-sarcomatous  tumour  in  the  left  hemisphere,  which  is  markedly  larger 
than  the  right. 

The  letter  A  points  to  the  niicleus  caudatus  ;  B,  to  the  optic  thalamus  ; 
and  C,  to  the  lenticular  nucleus  of  the  right  side. 

The  letter  D  points  to  the  left  or  internal  capsule,  which  was  com- 
pressed, and  to  some  extent  invaded  by  the  new  growth  ;  the  letter  E  points 
to  the  tumour. 

(3.)  Cerebral  symptoms  in  cases  of  intracranial  tumour  may  be  due 
to  associated  meningitis,  haemorrhage  into  the  substance  of  the  tumour 
and  surrounding  nerve  tissue,  or  other  accidental  complications. 

(4.)  The  presence  or  absence  of  constitutional  disturbance,  and  the 
nature  of  the  general  constitutional  symptoms,  depend  partly  upon 
the  character,  duration,  and  severity  of  the  nervous  symptoms  (pain, 
sleeplessness,  vomiting,  dysphagia,  &c.) ;  partly  upon  the  pathological 
nature  of  the  new  growth ;  but  are  chiefly  due,  more  especially  in  the 
earlier  stages  of  the  case,  to  associated  lesions  and  to  the  condition  of 
the  abdominal  and  thoracic  viscera. 

B 


1 8  GENERAL  PATHOLOGY. 

(5.)  The  severity,  botli  of  tlie  nervous  and  constitutional  symptoms, 
depends  to  some  extent  upon  the  individuality,  so  to  speak,  of  the 
patient.  The  capability  ^vhich  different  individuals  possess  of  bear- 
ing pain  and  of  resisting  disease  is,  as  we  all  know,  very  different. 
The  reaction,  both  to  ph^'siological  and  pathological  stimuli,  is  very 
different  in  different  cases.  It  is  reasonable,  therefore,  to  suppose 
that  a  cerebral  lesion  (tumour),  which  in  its  early  stages  produces 
in  one  individual  comparatively  trifling  symptoms,  may  give  rise  in 
another  to  profound  disturbances  (pain,  sleeplessness,  emotional  or 
mental  derangement,  &c.). 


CHAPTER    IL 

SYMPTOMATOLOGY  AND  CLINICAL  HISTOEY— ANALYSIS  OF 
INDIVIDUAL  SYMPTOMS. 

Clinical  Pictuees  presented  by  difeeeent  Geoups  of 
Inteaceanial  Tumoues. 

Although  the  symptoms  which  are  met  with  in  different  cases  of 
intracranial  tumour  are  very  different,  and  the  manner  in  which 
those  symptoms  are  arranged  in  individual  cases  is  subject  to  great 
variation,  it  is,  I  think,  possible  to  place  most  cases  in  one  or  other 
of  the  four  following  groups. 

1. — Cases  of  intracranial  tumour  in  loliicli  the  presence  of  the  tumour 
is  not  indicated  hy  any  characteristic  symptoms  during  life. 

Intracranial  tumours  are  sometimes  found  post  mortem  whose 
presence  was  not  suspected  during  life.  In  the  great  majority  of 
the  cases  of  this  description  there  are  cerebral  symptoms. 

In  some,  these  symptoms  are  characteristic ;  and  the  failure  in 
diagnosis  is  due,  either  to  the  circumstance  that  the  facts  on  which 
the  physician  has  to  base  his  opinion  are  wanting  (as  where  a  patient 
is  brought  into  hospital  in  a  state  of  coma,  and  dies  before  a  satis- 
factory history  of  the  case  is  obtained),  or  to  erroneous  observation  or 
deduction  on  the  part  of  the  medical  attendant. 

In  other  cases,  the  symptoms  produced  by  the  tumour  are  masked 
by  those  of  some  associated  lesion  or  complication — such,  for  instance, 
as  cerebral  meninojitis  or  cerebral  haemorrhage. 

In  very  rare  and  quite  exceptional  cases,  cerebral  symptoms 
are  absolutely  wanting.  One  of  the  most  remarkable  cases  of 
this  kind,  with  which  I  am  acquainted,  was  that  of  my  old  teacher, 
the  late  Professor  John  Hughes  Bennett,  who  died  after  the  operation 
of  lithotomy.  He  was,  as  is  well  known,  one  of  the  greatest  clinical 
teachers  of  his  time ;  and  his  keen  intellectual  powers  were,  I  under- 
stand, unimpaired  even  to  the  end.    He  certainly  never  manifested  any 


2  o  S  YMPTOMA  TOL  OGY. 

symptoms  suggestive  of  an  intracranial  tumour ;  nor  did  any  of  the 
many  eminent  physicians  whom  he  consulted  for  his  laryngeal  and 
other  troubles  ever  suspect  the  presence  of  such  a  lesion ;  and  yet  at 
the  autopsy,  a  tumour  the  size  of  a  hen's  egg  was  found  two  inches 
above  tlie  right  ear.  It  was  situated  between  the  dura  and  the  bone, 
and  projected  towards  the  brain  so  as  to  produce  a  deep  pit  or  hoUo'w, 
into  which  it  fitted.  The  parietal  bone  over  the  tumour  was  thinned  by 
pressure  and  absorption ;  at  one  point,  about  the  size  of  a  shilling,  all 
trace  of  bone  had  disappeared,  the  osseous  tissue  being  replaced  by 
fibrous  membrane ;  around  the  circumference  of  the  tumour  the  bone 
was  thickened  and  hypertrophied.  The  dura  mater  over  the  tumour 
was  thickened.  The  convolutions  were  flattened  and  pressed  down, 
but  not  otherwise  altered ;  there  was  no  congestion  and  no  softening 
in-  the  neighbourhood  of  the  new  growth.  ^  The  tumour  was  evidently 
stationary,  or  of  very  slow  growth.  Dr.  A.  Hughes  Bennett  tells  me 
that  the  tumour  was  probably  congenital,  for  the  Professor  had  fre- 
quently directed  his  attention  to  a  depression  of  the  skull  over  the  posi- 
tion of  the  tumour,  and  had  stated  that  it  had  existed  since  childhood. 

"We  must  conclude,  then,  that  in  some  rare  cases  (in  which  an 
intracranial  tumour  is  stationary  or  of  extremely  slow  growth;  in 
which  there  is  no  increase  of  intracranial  tension ;  and  no  irritation 
in  the  neighbourhood  of  the  lesion)  all  symptoms  may  be  entirely 
wanting.  I  repeat,  however,  that  in  the  great  majority  of  cases,  in 
which  the  tumour  appears  to  be  completely  "latent"  {i.e.,  unattended 
with  any  symptoms),  there  are  some  symptoms,  though  they  are  not 
in  all  cases  suggestive  or  characteristic  of  the  presence  of  a  new 
growth.  In  short,  I  agree  with  Obernier  in  thinking  that  "every 
tumour "  (I  should  say  every  growing  tumour)  "  of  any  size,  which 
presses  upon  or  injures  the  brain  tissue,  must  give  rise  to  symptoms, 
either  transitory  or  otherwise."^ 

In  speaking  of  the  absence  of  symptoms  in  some  cases  of  intra- 
cranial tumour.  Dr.  Hughlings  Jackson  makes  the  following  very 
suoojestive  remarks  : — "  Yet,  when  there  is  no  strikinLr  defect,  there 
may  be  dulling  of  mind  (slowness,  hebetude,  incapacity  for  continued 
mental   exertion)  ;    still   there   are  no   symptoms  which   make  the 

^  British  Medical  Journal,  9th  October  1875,  p.  453. 
"  Ziemssen's  Cydopcedia  of  Medicine,  vol.  xii.,  p.  241. 


CLINICAL  TYPES.  21 

patient  seek  a  doctor  until  perhaps  shortly  before  death.  The 
patient's  mind  may  be  so  generally  reduced  to  a  lower  level  that 
neither  he  nor  his  friends  notice  any  failure ;  or  they  may  notice 
'  alterations  '  of  disposition,  which  they  put  down  to  wrong  causes — 
to  the  influence  of  external  causes.  There  is  doubtless,  from  every 
degree  of  lesion  of  the  cerebral  hemisphere,  loss  of  some  special  or 
'  delicate '  intellectual  process,  and  correspondingly  of  some  of  the 
finer  emotions — for  every  intellectual  act  is  accompanied  by  emotion. 
To  adopt  an  expression  from  ophthalmology,  there  is  no  doubt  a 
'  limitation  of  the  mental  field,' — a  limitation  of  the  idea  of  con- 
sciousness." 1 

2. — Cases  in  luhich  the  characteristic  symptoms,  indicative  of  the  'presence 
of  a  tumour  in  some  part  of  the  intracranial  cavity,  are  present, 
hitt  in  which  there  are  no  symptoms  indicative  of  its  exact  site. 

In  typical  cases  of  this  kind,  headache,  vomiting,  and  charac- 
teristic changes  in  the  optic  discs  (double  optic  neuritis,  or  optic 
atrophy)  are  present ;  in  many  cases  there  is  also  vertigo. 

In  the  majority,  a  careful  comparison  of  the  previous  with  the 
present  mental  state  will  show  some  loss  of  mental  power,  some 
change  of  disposition,  some  derangement  of  intellect  or  mental  power, 
some  disturbance  of  the  emotional  faculties,  or  some  loss  in  the 
power  of  self-control.  In  not  a  few  cases  the  mental  alteration  is 
profound.  In  most  cases  of  this  kind  the  mental  symptoms  are  of  a 
negative  kind  ;  the  intellectual  deterioration  may  vary  from  a  slight 
loss  of  memory,  or  mere  dulling,  as  it  were,  of  mental  acuteness  on 
the  one  hand,  to  complete  loss  of  mental  power  (dementia  or  coma) 
on  the  other.  In  other  cases  there  is  irritability  of  temper  ;  and  in  a 
few — but  these  are  exceptional  and  rare — delusions,  excitement,  or  even 
violent  outbursts  of  acute  mania  occur.  A  more  detailed  description 
of  the  different  forms  of  mental  alteration  which  may  occur  in  this  and 
the  two  following — third  and  fourth  clinical  groups  of  intracranial 
tumours — is  reserved  until  the  individual  symptoms  are  analysed. 

In  many  cases  an  excess  of  phosphates  is  present  in  the  urine. 
In  some  the  appetite  is  voracious.     Pseudo-apoplectic  attacks,  or  true 

^  Lectures  on  the  Diagnosis  of  Tumours  of  the  Brain,  Medical  Times  and  Gazette,  23d 
August  1873. 


2  2  SYMPTOMATOLOGY. 

apoplectic  seizures — the  result  of  extravasations  of  blood  from  the 
thill  walled  vessels,  which  are  abundantly  present  in  some  forms  of 
tumour — may  occur. 

General  epileptiform  convulsions  are  sometimes  observed  ;  and  in 
some  cases  the  patient  dies  during  an  attack  of  tliis  kind. 

3.- — C(me8  in  which  the  symptoms  shoiu  not  only  that  a  tumour  is  present 
in  some  part  of  the  intracranial  cavity,  hut  in  ivhich  they  indi- 
cate, more  or  less  closely,  its  exact  locality  or  site. 

In  this  group  of  cases,  in  addition  to  headache,  vomiting,  double 
optic  neuritis,  or  post-neuritic  optic  atrophy,  &c.  (see  the  symptoms 
described  under  group  2),  symptoms  indicative  of  functional  dis- 
turbance of  special  parts  of  the  intracranial  contents  are  also 
present.  These  symptoms  may  be  due  to  functional  derangement 
(1)  of  limited  portions  of  grey  matter  ;  (2)  of  the  great  conducting 
paths  as  they  pass  through  the  intracranial  nerve  centres  ;  (3)  of 
involvement  of  one  or  more  of  the  cerebral  nerves  within  the  cavity 
of  the  cranium ;  or  (4)  implication  of  localised  portions  of  the 
cranial  walls. 

These  "  localising  "  symptoms,  as  they  are  termed,  are  numerous. 
The  more  important  are — localised  paralyses  or  spasms  of  the  muscles 
of  the  limbs,  face,  or  trunk ;  localised  derangements  of  the  tactile 
sensibility  of  the  skin  (anaesthesia  or  hyperfesthesia),  of  the  limbs,  face, 
head,  or  trunk  ;  localised  headache,  more  especially  when,  in  addition 
to  the  headache,  there  is  localised  tenderness  on  percussion  of  the 
painful  part ;  derangements  of  the  sense  of  sight,  other  than  the 
dimness  of  vision  and  limitation  of  the  visual  field  due  to  peripheral 
causes  —  in  other  words,  the  difi'erent  forms  of  hemianopsia, 
amblyopia,  or  amaurosis,  not  due  to  recognisable  ophthalmoscopic 
changes  in  the  optic  discs  ;  derangements  of  the  sense  of  hearing, 
smell,  or  taste,  other  than  those  which  result  from  peripheral  causes  ; 
the  various  forms  of  aphasia ;  special  forms  of  mental  deterioration, 
such,  for  instance,  as  the  loss  of  the  power  of  mental  concentration, 
which  seems  to  result  from  a  lesion  of  the  frontal  lobes  ;  urgent  and 
obstinate  vomiting ;  marked  vertigo  (when  due  to  central  causes) ;  a 
reeling  (cerebellar)  gait ;  polyuria  and  glycosuria  (the  result  of  central 
causes) ;  enlargement  of  the  head  ;  marked  difficulty  in  swallowing,  &c. 


CLINICAL  TYPES.  23 

The  bilateral  dimness  of  vision  (both  loss  of  acuity  of  vision  and 
contraction  of  the  fields),  which  is  the  result  of  optic  neuritis  or  post- 
neuritic optic  atrophy,  has  no  localising  value  ;  it  is  one  of  the 
common  symptoms  of  the  second  clinical  group. 

Localised  paralyses  in  the  muscles  of  the  trunk  are  rarely 
observed  as  the  result  of  chronic  cerebral  lesions,  for,  as  Dr.  Broad- 
bent  has  shown,  muscles  which  act  in  concert  can  be  put  into  action 
from  either  hemisphere.  Localised  spasms  in  the  trunk  muscles  do 
probably  occur  in  some  cases,  but  often  pass  unnoticed. 

By  means,  then,  of  these  localising  symptoms — and  more  particu- 
larly by  observing  the  manner  in  which  they  are  grouped  together — 
it  is  possible  in  some  cases  to  form  a  very  accurate  conclusion  as  to 
the  exact  locality  in  which  the  tumour  is  situated.  In  some  cases  (as, 
for  example,  when  the  "  general "  symptoms  of  a  tumour  are  present, 
together  with  hemiplegia)  it  may  not  be  possible  to  say  more  than 
that  the  tumour  involves  this  or  that  cerebral  hemisphere.  In  others, 
it  is  possible  to  locate  the  tumour  in  the  cerebellum,  pons  Varolii,  or 
medulla  oblongata  ;  in  others,  to  say  that  it  is  situated  at  the  base, 
or  in  the  frontal,  parietal,  temporo-sphenoidal,  or  occipital  lobe;  in 
others,  that  it  involves  the  corpus  callosum;  and  in  some,  that  it 
implicates  special  and  limited  areas  (centres)  of  the  motor  cortex. 

The  more  detailed  consideration  of  the  special  symptoms  indica- 
tive of  lesions  of  these  different  parts  is  reserved  until  the  diagnosis 
is  discussed. 

4. — Cases  in  which  there  are  distinct  indications  of  derangement  or 
disease  of  the  intracranicd  contents,  and  in  which  the  symptoms 
may  he  due  to  the  presence  of  an  intracranial  tumour,  hut  are  not 
typical  and  characteristic  of  that  condition. 

The  cases  included  in  this  group  often  give  rise  to  great  difSculties 
in  diagnosis. 

In  many,  the  symptoms,  taken  as  a  whole,  are  strongly  suggestive 
of  the  presence  of  an  intracranial  tumour,  but  some  striking  and 
characteristic  symptom,  which  is  necessary  to  clinch  the  diagnosis,  is 
"wanting ;  hence  there  is  difficulty  and  doubt. 

The  absence  of  characteristic  changes  in  the  optic  discs  is  the  fact 
which,  above  all  others,  is  apt  to  give  rise  to  difficulties  of  this  kind. 


2  4  S  YMPTOMA  TO  LOGY. 

The  absence  of  double  opLic  neuritis  or  post-neuritic  atrophy  does  not 
necessarily  exclude  tumour,  though  it  certainly  throws  doubt  upon 
the  diagnosis. 

If,  in  addition  to  the  fact  that  there  are  no  ophthalmoscopic  ap- 
pearances, localising  symptoms  are  also  wanting,  the  doubt  is  still 
further  increased. 

But  further,  when  the  headache,  vomiting,  and  other  "  general " 
symptoms  are  not  urgent  and  prominent,  the  doubt  may  become  so 
great,  that  it  may  be  impossible,  without  jumping  at  conclusions  and 
mere  guessing,  to  be  dogmatic,  and  give  a  positive  opinion  as  to  the 
nature  of  the  case.  The  difficulty  is  of  course  intensified  when  the 
patient  is  naturally  of  a  nervous,  emotional,  or  hysterical  tempera- 
ment ;  and  in  those  cases  in  which  hypermetropia,  anaemia,  ovarian 
irritation,  or  some  other  condition,  which  is  a  possible  cause  of 
headache  and  vomiting,  is  also  present. 

In  other  cases,  some  symptom  (such  as  localised  paralysis  or 
spasm)  clearly  indicative  of  a  localised  brain  lesion,  which  may  be  a 
tumour,  is  present,  but  the  general  symptoms  of  tumour  are  either 
altogether  absent  or  only  slightly  marked.  Optic  neuritis  may  be 
wanting;  or  headache,  vomiting  &c.,  may  be  altogether  absent  or 
very  slight. 

In  others,  again,  the  mental  disorganisation  or  derangement  may 
be  so  great  that  the  symptoms  of  tumour,  even  if  they  are  present, 
are  thrown  into  the  background  or  are  not  complained  of.  In  cases, 
for  example,  in  which  profound  dementia,  or  the  much  rarer  symptom 
acute  mania,  is  associated  with  an  intracranial  tumour,  the  physician 
who  has  not  had  the  opportunity  of  watching  the  case  from  the  com- 
mencement, or  who  has  no  satisfactory  record  of  the  previous  history 
and  condition,  may  never  suspect  the  presence  of  a  new  growth. 

For  the  same  reasons,  the  presence  of  well-marked  symptoms  of 
hysteria,  meningitis,  or  cerebral  htemorrhage,  or  the  fact  that  the 
patient  is  markedly  hypermetropic,  profoundly  antemic,  or  suffering 
from  Bright's  disease  or  plumbism,  may  throw  the  physician  off  his 
guard,  and  lead  him  in  some  cases,  very  naturally  (and  perhaps  not 
illogically),  to  overlook  the  presence  of  the  tumour,  and  to  conclude 
that  the  symptoms  are  entirely  due  to  the  presence  of  the  associated 
disease  or  pathological  condition. 


HEADACHE. 


25 


These  difficulties  will  be  still  further  appreciated  when  the 
differential  diagnosis  of  intracranial  tumours  is  more  minutely- 
considered. 

Analysis  of  Individual  Symptoms. 

After  this  general  sketch  of  the  more  important  symptoms  which 
may  be  present  in  the  different  clinical  groups  into  which  I  have 
divided  intracranial  tumours,  it  will  be  well  to  examine  the  indi- 
vidual symptoms  more  minutely,  and  to  consider  their  mode  of 
causation  and  diagnostic  value. 

Headache. 

Of  all  the  symptoms  of  intracranial  tumour,  headache  is  the  most 
frequent ;  it  is  usually  the  first  to  attract  attention,  and  is  very  fre- 
quently the  symptom  which  is  most  distressing  to  the  patient,  and  that 
which  most  urgently  demands  relief. 

In  the  great  majority  of  cases  of  intracranial  tumour  there  is 
more  or  less  headache.  In  some  the  pain  is  intense ;  the  patient 
may  describe  it  as  "  agonising,"  "  unbearable,"  or  may  say  he  feels  as 
if  his  "  head  would  burst."  The  severity  of  the  suffering  may  be  so 
great  as  to  suggest  the  idea  of  suicide.  ^  As  a  result  of  this  headache 
there  is  often  sleeplessness  and  great  exhaustion.  In  others,  the 
headache  is  comparatively  slight.  ^  In  a  small  proportion  of  cases  it 
is  altogether  absent.  In  some  cases  the  pain  is  dull  and  boring ;  in 
others,  shooting  and  neuralgic  in  character.  In  many,  the  headache 
is  paroxysmal  or  subject  to  paroxysmal  exacerbations  ;  in  others,  it  is 
more  or  less  constantly  present ;  in  some,  and  more  especially  (but 
not  exclusively)  in  syphilitic  cases,  the  pain  is  worse  at  night. 

In  many  cases  the  paroxysms  of  headache  are  associated  with 
vomiting  or  other  signs  of  cerebral  disturbance.  In  some  cases,  the 
patient  is  quite  free  from  pain  between  the  paroxysms.  The  length  of 
the   intervals  is  usually  quite  irregular;   but   in   a   few  cases  the 

^  See  a  case  of  glio-sarcoma  of  the  cerebellum,  reported  by  Dr.  Leslie  and  myself,  in 
the  Edinburgh  Medical  Journal  for  January  1887,  p.  591. 

^  See,  for  instance,  a  case  of  glioma  reported  by  me  in  the  Edinburgh  Medical 
Joiirnal  for  January  1887,  p.  623. 


2  6  ANAL  YSIS  OF  INDI VI D  UAL  S  YMPTOMS. 

paroxj^smal  exacerbations  seem  to  be  associated  with  menstruation, 
and  to  occur  periodically  every  month. 

Anything  which  deranges  the  cerebral  circulation,  such  as  hanging 
the  head  down,  rising  from  the  recumbent  to  the  erect  position, 
coughing,  sneezing,  laughing,  straining  at  stool,  &c.,  is  apt  to  aggi'a- 
vate  the  headache,  or  to  induce  a  paroxysm.  In  many  cases  the 
headache  is  felt  when  the  patient  first  gets  up  in  the  morning. 

The  occurrence  of  headache  and  vomiting  first  thing  in  the  morn- 
ing is  very  suggestive  of  a  cerebral  lesion,  but  alcoholic  dyspepsia 
and  some  other  conditions,  such  as  the  vomiting  of  pregnancy,  must 
be  excluded. 

TJie  position  of  the  pain  is  most  variable.  It  is  usually  described 
as  "  internal,"  but  in  some  cases  is  external  and  superficial.  In  some 
cases  it  is  referred  to  the  whole  head  ;  in  others,  it  is  limited  to  one 
side,  to  the  vertex,  or  to  the  frontal,  parietal,  or  occipital  region.  In 
a  certain  proportion  of  cases  it  is  very  limited  and  localised  ;  in  many 
of  these,  tenderness  on  skull  percussion,  or  even  on  gentle  pressure 
over  the  affected  spot,  is  present.  In  some,  localised  alterations  in 
the  bones  of  the  scalp  (such  as  thickenings  or  depressions,  syphilitic 
nodes,  &c.)  can  be  felt  at  the  point  of  tenderness.  In  some  cases,  in 
which  the  pain  is  neuralgic  in  character,  it  is  limited  to  the  area  of 
distribution  of  a  particular  branch  of  the  fifth  nerve. 

Tlu  causation  of  headache  in  cases  of  intracranial  tumour  is 
probably  various. 

The  most  common  cause  is  probably  increased  intracranial  tension, 
with  resulting  stretching  of  the  membranes  and  irritation  of  (both  as 
a  result  of  stretching  of,  and  pressure  on)  the  sensory  nerve  fibres 
distributed  to  the  membranes  of  the  brain  and  the  cranial  parietes. 
If  this  is  so,  we  should  naturally  expect  headache  to  be  most  promi- 
nent and  severe  in  those  cases  in  which  greatly  increased  intracranial 
pressure  is  quickly  produced  {i.e.,  in  large,  quickly  growing  tumours). 
AVhen  the  increased  intracranial  pressure  is  slowly  established,  and 
more  especially  in  those  cases  in  which  (in  consequence  of  dropsy  of  the 
ventricles,  a  general  cedematous  condition  or  marked  anaemia  of  the 
brain  tissue)  the  cerebral,  sensibility  is  dulled,  little  or  no  headache 
may  be  complained  of. 

In  some  cases  the  headache  is  due  to  direct  involvement  of  the 


HEADACHE.  27 

membranes,  periosteum  or  bones,  by  the  tumour,  or  by  the  inflam- 
matory changes  produced  in  the  immediate  neighbourhood  of  the  new 
growth,  with  consequent  pressure  on,  or  inflammatory  irritation  of, 
the  branches  of  the  fifth  nerve  which  are  distributed  to  the  affected  part. 

The  effect  which  rapid  alterations  in  the  cerebral  circulation,  such 
as  are  produced  by  sudden  rising  from  the  recumbent  to  the  erect 
position,  sneezing,  coughing,  &c.,  may  have  in  aggravating  the  head- 
ache has  already  been  alluded  to.  Vice,  versa,  the  relief  which  is  in 
some  cases  afforded  by  free  purgation,  the  application  of  cold  to  the 
head,  and  the  administration  of  remedies  which  reduce  the  arterial 
blood  pressure,  will  be  afterwards  described  in  more  detail. 

In  some  cases  headache  is  due  to  direct  implication  of  the  trunk 
of  the  fifth  nerve,  or  of  some  of  its  larger  branches ;  and  in  such 
cases  the  pain  is  referred  (in  accordance  with  the  law  of  eccentric 
projection)  not  so  much  to  the  seat  of  the  lesion,  as  to  the  area  of 
distribution  of  the  affected  nerve. 

In  some  cases  the  headache  of  intracranial  tumour  is  perhaps  the 
result  of  a  nerve  storm,  similar  in  character  to  that  which  produces 
the  pain  of  ordinary  sick  headache  or  migraine.  Such,  at  all  events, 
was  the  late  Dr.  Hilton  Fagge's  view.  He  writes — "  ISTow  my 
hypothesis  is  that  a  tumour  or  tubercle  causes  a  transitory  vertigo,  or 
an  epileptiform  attack,  or  an  attack  of  sick  headache,  in  exactly  the 
same  way  as  any  other  disturbing  agent.  I  conceive  that  the  nerve 
storm  so  produced  has  exactly  the  same  effect  as  when  it  is  merely 
the  result  of  over-fatigue,  or  irritation  of  the  generative  organs,  or 
disorder  of  the  stomach.  And  I  think  it  is  probable  that  frontal 
headache,  even  when  unattended  with  the  other  characteristic 
symptoms  of  an  attack  of  migraine,  is  yet  very  often  of  that  nature. 
If  this  be  granted,  it  ought  to  follow  that  pain  in  the  forehead  should 
point  less  directly  to  the  anterior  part  of  the  brain  as  the  seat  of  a 
tumour,  than  occipital  pain  to  the  cerebellum  or  posterior  lobes.  I 
do  not  know  whether  growths  situated  in  any  particular  region  are 
more  apt  than  others  to  be  accompanied  by  vertigo  or  epileptiform 
convulsions,  as  distinguished  from  those  seizures  which  are  limited  to 
the  muscles  of  certain  parts,  and  to  which  I  shall  presently  refer. 
But  Dr.  Eussell  Eeyuolds  was  led,  by  the  examination  of  a  large 
number  of  cases,  to  the  conclusion  that  convulsions  in  general  were 


28  ANAL  YSIS  OF  INDI VID  UAL  S  YMPTOMS. 

less  common  when  the  disease  affected  the  anterior  lobes  than  when 
it  occupied  the  posterior  lobes  or  the  cerebellum."  ^ 

The,  diagnostic  value  of  headache  as  a  symptom  of  intracranial 
tumour. — Headaclie  is  such  a  common  symptom,  and  may  be  due  to  so 
many  different  conditions,  both  functional  and  organic,  that  'per  se  it 
is  not  of  much  importance  as  an  indication  of  serious  organic  cere- 
bral disease  (e.g.,  tumour)  unless  it  is  very  persistent  and  severe,  and 
unless  all  the  other  conditions  which  may  give  rise  to  headache  can 
be  excluded. 

But  since  it  is  the  most  frequent  of  all  the  symptoms  of  intra- 
cranial tumour,  it  is  of  great  importance  when  associated  with  other 
general  symptoms  (vomiting,  and  more  especially  double  optic  neuritis) 
indicative  of  tumour,  or  when  distinct  indications  of  a  localised  cere- 
bral lesion,  such  as  localised  spasms  or  paralysis,  are  present. 

While  it  may  be  stated  that  in  the  absence  of  headache  a  positive 
diagnosis  of  intracranial  tumour  is  seldom  possible,  it  must  be 
remembered  that  the  absence  of  headache  does  not  absolutely 
exclude  tumour. 

It  must  also  be  remembered  that  headache  is  often  a  prominent 
symptom  in  the  very  conditions  which  are  most  liable  to  be  con- 
founded with  tumour — such  as  Bright's  disease,  plumbism,  errors  of  re- 
fraction with  anaemia,  migraine,  extracranial  syphilis,  meningitis,  &c. 

The  localising  value  of  headache  is  not  as  a  rule  great.  Frontal 
headache  more  especially  is  apt  to  mislead  the  observer.  In  some 
cases,  however,  the  pain  corresponds  more  or  less  closely,  and  in  a  few 
cases  most  accurately,  to  the  position  of  the  tumour.  In  many  sub- 
tentorial  (cerebellar)  tumours  the  pain  is  chiefly  referred  to  the  back 
of  the  head ;  and  in  tumours  of  one  hemisphere  it  is  not  very  uncom- 
mon to  find  the  pain  located  on  one  (the  same)  side  of  the  head.  The 
localising  value  of  headache  is  much  increased  if,  in  addition  to  the 
fact  that  the  pain  is  confined  to  a  limited  area,  there  is  also  tender- 
ness on  percussion,  or  some  other  local  alteration  (such  as  a  depression 
or  swelling  on  the  surface  of  the  cranium)  at  the  seat  of  the  pain. 

Localised  pain,  with  tenderness  on  pressure,  suggests  very  strongly 
that  the  tumour  is  superficial,  and  that  the  bone  or  membranes  are 
affected.      In  syphilitic  cases,  in  which   the    pain  is  often  of  this 

^  Principles  and  Piactice  of  Medicine,  voL  i.,  p.  526. 


HEADACHE.  29 

character,  and  indeed  in  all  cases  in  which  it  is  superticial  and  localised 
to  one  part  of  the  cranial  wall  it  may  of  course,  be  the  result  of  an 
ex'^rftcranial  as  well  as  intracranial  lesion. 

In  those  cases  in  which  the  pain  in  the  head  is  superficial  and 
neuralgic  in  character,  the  fact  that  it  is  felt  in  the  areas  of  distribu- 
tion of  all  the  branches  of  tlie  fifth  nerve  makes  it  much  more  pro- 
bable that  it  is  due  to  central  disease  {e,.cj.,  pressure  on  the  nerve  vnthin 
the  cavity  of  the  cranium)  than  when  one  division  only  of  the  nerve 
is  involved. 

In  illustration  of  the  very  definite  manner  in  which  pain  and  other 
abnormal  sensations  are  sometimes  limited  to  the  exact  seat  of  the 
intracranial  tumour,  the  following  statement  of  Hilton  Fagge  may  be 
quoted  : — ''  The  museum  of  Guy's  Hospital  contains  a  large  tumour, 
three  inches  in  diameter,  which  I  found  many  years  ago  in  the  left 
hemisphere  of  a  girl,  a  patient  of  Dr.  Wilks,  who  suffered  severely 
from  pain  in  the  head,  and  who  had  declared  that  when  she  turned 
her  head  to  one  side  she  felt  something  move  in  its  interior.  Another 
preparation  consists  of  a  small  growth  from  the  dura  mater,  taken 
by  Dr.  Day,  of  St.  Neots,  from  an  old  woman  who  died  of  bronchitis. 
She  had  often  expressed  a  wish  that  her  head  should  be  opened, 
because  for  years  she  had  experienced  anomalous  pains  in  it,  and  a 
sensation  of  coldness  at  one  spot,  not  larger  than  a  shilling ;  this  cor- 
responded very  nearly  with  the  seat  of  the  tumour,  which  was  found 
after  her  death."  ^ 

The,  diagnostic  value  of  headache  in  a  pathological  sense  is  not,  as  a 
rule,  great. 

Wlien  slight,  or  altogether  absent,  we  expect  the  tumour  to  be 
stationary  or  of  very  slow  growth.  The  reverse  does  not  hold  good, 
for  a  slow  growing  tumour  may  be  attended  with  very  severe  headache. 
In  a  case  of  cerebellar  tumour  of  several  years  duration,  which  I  have 
reported  in  conjunction  with  Dr.  Leslie,  the  headache  was  so  severe 
as  to  suggest  the  idea  of  suicide  to  the  patient ;  and,  speaking  gene- 
rally, we  infer,  in  cases  of  this  description,  that  the  tumour  is  simple 
(non-malignant),  localised,  and  encapsuled,  rather  than  malignant  and 
diffused.  Aneurisms  on  the  large  vessels  at  the  base  of  the  brain 
may  even,  when  of  considerable  size,  be  unattended  with  headache. 

^  Piinciples  and  Practice  of  Medicine^  vol.  i.,  p.  328. 


30  ANALYSIS  OF  INDIVIDUAL  SYMPTOMS. 

In  many  cystic  tumours,  and  in  many  gliomata,  the  pain  is  very  slight ; 
but  in  other  tumours  of  the  same  patliological  structure  tlie  reverse  is 
the  case.  In  the  Ediriburgh  Medical  Journcd  for  January  1887,  pj). 
591  and  623,  I  have  reported  two  cases  of  sarco-glioma,  with  hyaloid 
degeneration,  and  the  formation  of  large  cysts.  The  pathological 
structure  of  the  two  tumours  was  identically  the  same ;  in  both,  the 
tumour  had  evidently  been  of  slow  formation  and  very  slow  growth. 
In  one,  in  which  the  new  growth  was  situated  in  the  left  frontal 
lobe,  there  was  no  increased  intracranial  tension  (verified  post 
mortem),  and  there  had  been  no  optic  neuritis,  very  slight  headache, 
little  or  uo  vomiting.  In  the  other,  in  which  the  tumour  involved 
the  cerebellum,  very  great  increase  of  the  intracranial  pressure  was 
found  after  death,  while  during  life  agonising  headache,  very  urgent 
vomiting,  and  intense  optic  neuritis  were  present.  The  difference  in 
the  symptoms  in  these  two  cases  was  jjrobably  due  to  the  difference 
in  the  position  of  the  tumour,  and  to  the  different  effects  which  were 
produced  as  regards  the  intracranial  pressure  ;  for,  as  previously 
remarked,  the  pathological  character  of  the  tumour  was  in  both  cases 
identically  the  same. 

In  sliomatous  tumour  of  the  cerebrum  itself  headache  is  not 
infrequently  absent;  thus,  in  a  hundred  cases  of  cerebral  tumour, 
analysed  by  Drs.  Mills  and  Lloyd,  it  is  stated  that  there  was  no 
headache  in  only  five  (no  mention,  however,  being  made  of  the 
presence  or  absence  of  headache  in  twenty-six).  Three  of  these  five 
were  found  to  be  gliomata ;  of  the  remaining  two,  one  was  probably 
gliomatous,  and  the  other  a  cyst  in  the  brain  substance.  ^  The  fact 
that  the  pain  is  worse  at  night  is  very  suggestive  (though  not 
pathognomonic)  of  the  syphilitic  character  of  the  tumour. 

In  many  of  the  cases  in  which  the  pain  is  localised  to  a  particular 
part  of  the  cranial  wall,  and  associated  with  tenderness  on  pressure 
(okull  percussion),  the  tumour  is  syphilitic  or  malignant  in  character. 

VomitiiKj. 
Next  to  headache  and  double  optic  neuritis,  vomiting  is  probably 
the  most  common  symptom  of  intracranial  tumours.     In  some  cases 
it  is  very  severe  and  distressing.     The  great  characteristic  of  cerebral 

*   Pepper'b  System  of  ihdiciiu,  vol.  v.,  p.  1033. 


VOMITING.  31 

vomiting  is  that  it  is  purposeless — i.e.,  that  it  occurs  without  obvious 
cause,  at  irregular  intervals,  and  that  it  does  not  necessarily  have 
any  fixed  relationship  to  the  ingestion  of  food  or  drink.  Cerebral 
vomiting  is  often,  though  by  no  means  always,  associated  with  a  clean 
tongue.  It  may  be  unattended  with  nausea,  but  is  often  followed  by 
marked  exhaustion.  In  many  cases  it  is  paroxysmal,  and  is  associated 
with  exacerbations  of  the  headache.  Like  headache,  it  is  often  ap- 
parently due  to  disturbance  of  the  cerebral  circulation ;  and  fre- 
quently occurs  before  breakfast,  when  the  patient  first  rises  from  the 
recumbent  to  the  erect  position. 

Tlu  causation  of  vomiting  in  cases  of  cerebral  tumour. — Like  head- 
ache, vomiting  is  in  many  cases,  I  believe,  due  to  the  irritation  of  the 
sensory  nerve  fibres  in  the  cerebral  membranes — the  result  either  of 
increased  intracranial  pressure,  or  of  direct  involvement  by  the 
new,  growth  or  by  the  inflammatory  changes  in  its  neighbourhood. 
Possibly  in  some  cases  vomiting  may  be  caused  reflexly  by  irritation 
originating  in  the  tissues  of  the  brain  itself. 

The  effect  which  derangements  of  the  cerebral  circulation  have  in 
producing  vomiting,  and  Dr.  Hilton  Fagge's  views  as  to  the  relation- 
ship of  the  vomiting  in  cases  of  cerebral  tumour  and  in  migraine, 
have  been  already  alluded  to. 

Direct  irritation  of  the  "  vomiting  centre "  in  the  medulla 
oblongata,  by  a  tumour  in  its  immediate  neighbourhood,  is  another 
way  in  which  very  severe  and  obstinate  vomiting  may  be  produced. 

It  is  also  probable  that  in  some  cases  of  cerebral  tumour,  in  which 
there  is  severe  vertigo,  vomiting  may  be  due  to  an  "overflow"  of 
irritation  from  the  vertiginous  to  the  vomiting  centre. 

The  diagnostic  value  of  vomiting  in  cases  of  cerebral  tumour. — 
Although  vomiting  is  a  very  frequent  symptom  in  cases  of  intra- 
cranial tumour,  it  is  per  se  of  little  diagnostic  value,  for  so  many  other 
different  conditions  may  produce  it.  In  estimating  the  value  of 
vomiting  as  a  sign  of  intracranial  tumour,  it  is  of  course  necessary  to 
exclude  derangements  of  the  stomach  and  other  abdominal  causes; 
and  to  satisfy  oneself  that  the  vomiting  is  cerebral.  It  is  also  neces- 
sary to  remember  that  vomiting  is  often  a  prominent  symptom  in 
many  of  the  conditions  which  most  closely  resemble  intracranial 
tumour,- such   as  meningitis,   Bright's  disease,   plumbism,   migraine. 


32  ANAL  YSIS  OF  INDIVID  UAL  S  YMPTOMS. 

hysteria.  Care,  too,  must  be  taken  not  to  confound  the  morning 
sickness  due  to  alcoholismus,  or  pregnancy,  with  that  due  to  an  intra- 
cranial tumour. 

As  a  localising  symptom,  and  as  an  indication  of  the  pathological 
character  of  the  new  growth,  vomiting  is  not  of  much  value.  The 
greater  the  cerebral  and  meningeal  irritation,  the  greater,  as  a  rule, 
the  vomiting.  Those  tumours,  therefore,  which  grow  rapidly,  which 
produce  rapid  increase  of  the  intracranial  pressure,  and  which  cause 
meningitis  (such  as  syphilitic,  tubercular,  and  malignant  tumours), 
are,  other  things  being  equal,  the  most  likely  to  produce  vomiting. 

Tumours  which  are  situated  far  forward  (tumours  of  the  frontal 
lobe,  for  example)  seem  to  be  less  frequently  associated  with  severe 
vomiting  than  those  which  are  situated  far  back  (subtentorial 
tumours,  for  instance).  In  short,  the  nearer  the  tumour  is  to  the 
"  vomiting  centre,"  the  greater  is  the  tendency,  other  things  being 
equal,  to  the  production  of  vomiting.  Very  severe  and  very  obsti- 
nate vomiting  is  therefore  suggestive  of  a  lesion  in  the  neighbourhood 
of  the  pons  Varolii  or  medulla  oblongata.  There  are,  however,  so 
many  sources  of  fallacy  in  connection  with  this  point,  that  the  local- 
ising value  of  vomiting  is  not  great. 

V&rtigo. 

This  is  another  very  common  symptom  in  cases  of  intracranial 
tumour.  It  is  usually  slight  and  transitory,  but  is  sometimes 
both  persistent  and  severe.  In  many  cases  the  giddiness  is  pro- 
duced or  aggravated  by  suddenly  rising  from  the  recumbent  to  the 
erect  position,  stooping  the  head  forward,  &c.  In  most  cases  the 
patient  simply  feels  giddy;  in  some,  he  feels  as  if  surrounding 
objects  were  moving  in  some  particular  direction.  In  a  few  cases  the 
vertigo  is  "  active,"  and  the  patient  feels  as  if  he  himself  were  being 
moved  or  whirled  through  space.  In  one  of  my  cases,  in  which 
vertigo  was  very  distressing,  the  patient  stated  that  the  ceiling  seemed 
to  be  constantly  falling  down  upon  the  top  of  her.  In  that  case,  the 
tumour — a  large  secondary  cancerous  nodule  (see  Fig.  7) — was 
situated  in  the  right  lobe  of  the  cerebellum. 

Tumours  of  the  middle  lobe  of  the  cerebellum  are  frequently 
attended   with    severe    vertigo.     This    is,    however,  by   no    means 


VERTIGO. 


33 


always  so ;  see,  for  example,  the  case  of  melanotic  sarcoma,  which 
I  have  reported  in  conjunction  with  Dr.  Allan  Jamieson,  in  the 
Edinlurgh  Medical  Journal  for  July  1887,  and  which  is  represented 
in  Fis.  8, 


I'iG.  7.  — Transverse  section  through  the  cerebellum  and  pons  "VaroHi, 
showing  a  large  nodule  of  secondary  cancer  in  the  right  lateral  lobe  of  the 
cerebellum.    The  letter  H  points  to  the  tumour  ;  /,  to  the  pons  Varolii. 

The  right  middle  peduncle  of  the  cerebellum  was  compressed  by  the  new 
growth.     (The  case  is  reported  in  Brain,  January  1888,  page  503.) 

The  causes  of  vertigo  in  cases  of  cerebral  tumour  are  various.  In 
many  cases  it  is  probably  due  to  temporary  derangements  of  the 
cerebral  circulation ;  in  others  it  is  probably  the  result  of  irritation 
of  the  cerebral  membranes,  caused  by  increased  intracranial  pressure, 
meningitis,  &c. ;  in  some  it  is  perhaps  due  to  irritation  originating 
in  the  brain  tissue  itself.  In  a  few  cases — and  these  are  the  cases  in 
which  the  vertigo  is  most  distressing  and  severe — it  is  due  to  direct 
irritation  of  some  part  (of  the  intracranial  portion)  of  the  mechanism 
concerned  in  the  regulation  of  the  head  to  the  plummet  line  of  the 
body.  Tumours  which  involve  the  cerebellum  or  medulla  oblongata, 
or  which  press  upon  the  eighth  nerve  (portio  mollis  of  the  seventh 

c 


34 


ANALYSIS  OF  INDIVIDUAL  SYMPTOMS. 


nerve),  may  probably  produce  giddiness  in  this  way.  Drs.  Mills  and 
Lloyd  also  suppose  that  vertigo  may  be  due  to  pressure  on  the 
labyrinth.  They  say — "  Experiments  have  demonstrated  the  existence 
of  a  communication  between  the  arachnoid  ca\dty  and  the  labyrinth, 

and  consequently  the  increased 
intracranial  tension  present  may 
result  in  pressure  on  the  labyrin- 
thine fibres  of  the  auditory  nerve, 
and  thus  occasion  vertigo."  ^  In 
some  cases  the  vertigo  is  probably 
ocular.  A  cerebral  tumour  may 
cause  paralysis  of  some  one  or 
other  of  the  muscles  of  the  eye- 
ball, in  consec[uence  of  which 
ocular  vertigo  is  developed.  As 
we  might  a  i^riori  suppose,  this 
form  of  giddiness  is  not  common, 
even  in  those  cases  in  which  a 
cerebral  tumour  does  produce  an 
ocular  paralysis ;  for  ocular  ver- 
tigo is  chiefly  met  with  as  the 
result  of  a  quickly  established 
(recent)  ocular  paralysis.  In 
those  cases  in  which  the  paralysis 


Fig.  8.  —  Transverse  vertical  section 
through  the  brain  in  a  case  of  melanotic 
sarcoma,  showing  numerous  melanotic  de- 
posits both  in  the  brain  and  cerebellum. 
(Reduced  from  a  photograph.) 

The  letter  U  points  to  a  nodule  of  some 
size  in  the  left  lateral  lobe  of  the  cere- 
bellum ;  V,  to  the  left  lateral  verticle  ;  W 
and  X  to  large  nodules  in  the  right  cerebral 
hemisphere  ;  Y  to  a.  large  nodule  in  the 
middle  lobe  of  the  cerebellum. 

Vertigo  was  never  complained  of  during 
the  whole  course  of  the  case,  which  is  re- 
ported in  the  Edinburgh  Medical  Journal 
for  July  1887. 


is  slowly  established  or  of  long 
duration — as  it  is  in  many  cases  of  ocular  paralysis  due  to  cerebral 
tumour — the  nerve  centres  accommodate  themselves  to  the  double 
vision,  and  the  vertigo  disappears,  or  is  aot  produced. 

The  diagnostic  value  of  vertigo  in  cases  of  cerehral  tumour  is  per  se 
not  great.  It  is  necessary,  of  course,  to  exclude  all  the  other  possible 
causes  of  giddiness,  more  especially  Meniere's  disease,  in  which  many 
of  the  symptoms  are  identical  with  those  of  cerebellar  tumour;  and 
it  is  only  when  other  symptoms  of  tumour  are  present  that  the 
vertigo  can  with  any  degree  of  confidence  be  attributed  to  this  cause. 
Very  severe  vertigo,  in  combination  with  other  symptoms  indicative 


^  Pepper's  System  of  Medicine,  vol.  v.,  p.  1035. 


VERTIGO.  35 

of  a  tumour,  suggests  that  the  new  growth  is  situated  in  the  cere- 
bellum (possibly  in  the  middle  lobe) ;  or  that  it  involves  the  intra- 
cranial portion  of  the  eighth  nerve  (portio  mollis).  In  the  latter  case, 
marked  unilateral  deafness,  from  involvement  of  the  auditory  fibres, 
and  very  probably  facial  paralysis,  from  implication  of  the  portio  dura 
or  seventh  nerve,  would  probably  be  present. 

Marked  vertigo,  unilateral  deafness,  and  facial  paralysis,  when 
there  is  no  apparent  lesion  of  the  ear — when  associated  with  other 
symptoms  of  an  intracranial  tumour — are  indicative  of  a  tumour 
at  the  base. 


CHAPTER    III. 

CHANGES     IN     THE    FUNDUS     OCULI— DOUBLE     OPTIC 
NEURITIS   AND   OPTIC   ATROPHY. 

Of  all  the  symptoms  of  intracranial  tumour,  double  optic  neuritis  is 
the  most  important ;  firstly,  because  it  is  an  objective  sign,  which 
does  not  depend  upon  the  mere  sensations  and  statements  of  the 
patient,  but  which  is  attended  with  distinct  physical  alterations 
wliich  can  be  seen  by  the  physician  ;  secondly,  because  it  is  present  in 
the  great  majority  of  cases  of  intracranial  tumour  at  some  j^criod  or 
other  of  their  course  ;  and  thirdly,  because,  unlike  headache,  vomiting, 
and  vertigo,  it  is  a  symptom  which  is  not  commonly  produced  by 
other  conditions  ;  or,  to  state  the  matter  more  accurately,  an  intra- 
cranial tumour  is  by  far  the  most  common  condition  which  is 
associated  with  double  optic  neuritis. 

The  degree  of  change  in  the  optic  discs  may  vary  from  mere 
engorgement  of  the  veins,  without  swelling  of  the  disc  or  blurring  of 
its  edges,  up  to  the  most  intense  neuritis. 

In  the  vast  majority  of  cases  the  optic  neuritis  associated  with 
intracranial  tumours  is  bilateral,  though  it  very  frequently  happens 
that  the  changes  are  more  marked  in  one  eye  tlian  in  the  other. 
Cases  are  occasionally  met  with  in  which  the  neuritis  is  confined  to 
one  disc.  Dr.  Hughlings  Jackson  thinks  that,  in  cases  of  this 
description,  the  disc  on  the  opposite  side  to  the  brain  lesion  is  more 
frequently  affected  than  tliat  on  the  same  side ;  but  whether  this  is 
more  than  accidental,  and  whether  it  is  a  point  of  any  importance,  is 
perhaps  doubtful.  The  number  of  cases  of  intracranial  tumour  in 
which  the  papillitis  has  been  unilateral  is,  in  my  opinion,  too  small 
to  allow  of  any  very  definite  generalisation  being  made. 

In  Figs.  9, 10,  and  11  the  appearances  of  the  fundus  oculi  in  health 
and  in  papillitis  are  represented. 

After  an  inflammatory  condition  of  tlie  discs  has  lasted  some  time. 


DOUBLE  OPTIC  NEURITIS.  37 

vision  is  usually  more  or  less  affected  ;  aucl  in  many  cases,  even  if  the 
optic  neuritis  should  subside  and  completely  disappear,  some  atrophy 
of  the  optic  discs,  with  more  or  less  impairment  of  vision,  remains. 


Fig.  9. — The  normal  fundus  oculi.     (Indirect  image.) 

But  while  vision  is  usually  affected  sooner  or  later,  and  to  a 
greater  or  less  degree,  in  long- continued  optic  neuritis,  it  is  of  the 
utmost  importance  to  remember  that  it  (both  the  acuity  of  vision 
and  the  extent  of  the  visual  field)  may  be  absolutely  normal,  even 
when  marked  double  optic  neuritis  can  be  seen  with  the  ophthalmo- 
scope. One  of  the  most  striking  cases  of  this  kind  which  have  come 
under  my  observation  was  that  of  a  man  aged  twenty-three,  who  was 
recently  sent  to  me  by  Dr.  Berry,  suffering  from  well-marked  double 
optic  neuritis  of  some  weeks'  duration.  The  exact  causation  was 
obscure  ;  he  had  apparently  had  an  attack  of  meningitis,  characterised 
by  headache,  vomiting,  and  elevation  of  temperature  ;  there  was  some 
double  visipn,  but  there  were  no  symptoms  which  enabled  me  to 
diagnose  positively  an  intracranial  tumour,  and  a  guarded  opinion 
was  given.     The  double  optic  neuritis,  which  was  very  marked,  and 


38  ANALYSIS  OF  INDIVIDUAL  SYMPTOMS. 

Mliicli  is  represented  in  Fig.  11,  lasted  fur  many  weeks,  but  ultimately 
completely  disappeared  under  the  continued  administration  of  large 
doses  of  iodide  of  potassium.  The  acuity  and  the  field  of  vision, 
which  were  regularly  examined,  were  ne\'er  in  the  least  degree 
impaired  ;  both  at  the  height  of  the  condition  and  after  all  inflamma- 
tory changes  had  disappeared  they  remained  absolutely  normal.  The 
patient  had  not  had  syphilis. 


Fig.  10. — Fundus  oculi  in  a  case  of  intracranial  tumour,  show'ing  well- 
marked  papillitis.     (Indirect  image. ) 

The  disc  is  markedly  swollen,  and  its  edges  ill  defined.  The  vessels  are 
obscured,  more  especially  where  they  pass  over  the  edge  of  the  swollen  disc. 

I  have  reported  several  cases  of  cerebral  tumour,  one  of  which  is 
represented  in  Figs.  1,  2,  3,  and  4  (see  pages  11-14),  in  which  well- 
marked  optic  neuritis  was  associated  with  good  or  perfect  central 
vision ;  and  this  fact,  which  was  long  ago  insisted  upon  by  Dr. 
Hughlings  Jackson,  is  now  widely  recognised  by  all  competent 
authorities.  In  reference  to  this  point  Dr.  Stephen  Mackenzie  states 
that  "  he  would  go  so  far  as  to  say  that  in  the  practice  of  physicians 
who  examined  all  their  cases  with  the  ophthalmoscope,  whether  the 


DOUBLE  OPTIC  NEURITIS.  39 

case  was  a  cerebral  one  or  otherwise,  at  least  in  one-half,  if  not  more, 
of  the  cases  in  which  optic  neuritis  was  discovered  it  would  be  found 
unassociated  with  any  marked,  and  often  without  apparent  appreciable 


Fig.  11. — Fundus  oculi  in  a  case  of  well-marked  papillitis.  (Indirect 
image. ) 

Both  the  arteries  and  veins  are  obscured  as  they  pass  over  the  edge  of 
the  swollen  disc.  Two  ha;morrhages  are  seen  on  the  disc  ;  several  minute 
hagmorrhages  could  be  seen  on  the  swollen  disc  by  the  direct  method  of 
examination. 

The  veins  are  drawn  rather  too  small, 

defect  of  sight,"  ^  while  Dr.  Buzzard  stated  in  the  same  debate 
that  "he  continually  found — indeed,  he  thought  it  was  the  rule — 
that  persons  in  whom  the  optic  discs  were  greatly  swollen  not 
only  had  no  complaint  to  make  of  their  sight,  but  could  read  the 
smallest  type."  ^ 

*  Transactions  of  the  Ophthalmological  Society  of  the  United  Kingdom,  vol.  i.,  p.  97. 
-  Ibid.,  p.  97. 


40  ANALYSIS  OF  INDIVIDUAL  SYMPTOMS. 

The  fact  that  there  may  be  little  or  no  defect  of  vision  when  there 
is  well-marked  optic  neuritis,  shows  the  fallacy  of  trusting  to  the 
condition  of  vision  as  an  index  of  the  state  of  the  fundus  oculi, 
and  teaches  the  necessity  of  the  routine  use  of  the  ophtlialmoscope. 
Whenever,  in  short,  there  is  any  reason  to  suspect  intracranial  disease 
— more  especially  tumour — the  fundus  oculi  should  be  examined  with 
the  ophthalmoscope.  It  is  not  too  much  to  say  tliat  the  ophthalmoscope 
is  quite  as  important  in  the  diagnosis  of  some  nervous  affections,  as  the 
stethoscope  is  in  the  diagnosis  of  some  cardiac  and  respiratory  diseases. 
The  routine  use  of  the  one  is  just  as  necessary,  if  mistakes  are  to  be 
avoided,  as  the  routine  use  of  the  other ;  for  just  as  some  serious  cardiac 
affections — aortic  regurgitation,  for  example — may  be  unattended  by 
symptoms,  but  readily  detected  on  stethoscopic  examination,  so  the 
double  optic  neuritis,  which  is  easily  enough  seen  in  most  cases  by 
means  of  the  ophthalmoscope,  may  be  unattended  with  any  alteration 
of  the  visual  acuteness,  or  indeed  any  limitation  of  the  field  of  vision. 

In  the  majority  of  cases  the  optic  neuritis  commences  gradually 
and  continues  for  a  long  time.  As  a  rule,  too,  the  dimness  of  vision 
due  to  optic  neuritis,  or  resulting  optic  atrophy,  is  slowly  and  gradu- 
ally established.  Cases  are,  however,  met  with  in  which  total  loss  of 
vision  occurs  suddenly.  I  have  reported  a  case  of  cerebellar  tumour 
with  extensive  ventricular  dropsy,  in  which  sight  and  hearing  were 
both  quickly  lost ;  and  Dr.  Hilton  Fagge  mentions  a  case  in  which 
sudden  loss  of  vision  also  occurred. 

Double  optic  neuritis  is  essentially  a  "  gcnerar'  and  not  a  localis- 
ing symptom;  for  it  may  result  from  tumours  in  any  part  of  the 
cranial  cavity.  In  the  very  few  cases  of  cerebral  tumour  in  which 
the  optic  neuritis  is  confined  to  one  eye,  the  tumour  has  been  found 
in  the  opposite  cerebral  hemisphere.  Unilateral  optic  neuritis  {i.e., 
neuritis  confined  throughout  the  course  of  the  case  to  one  eye),  is, 
however,  strongly  suggestive  of  local  disease  in  the  eyeball  or  orbit,  or  of 
localised  pressure  on  the  optic  nerve  in  front  of  the  optic  cliiasma, 
rather  than  of  an  intracranial  tumour. 

In  estimating  the  diagnostic  value  of  douhle  optic  neuritis  as  a  sign 
of  intracranial  tumour,  it  must  be  remembered — 

Firstly.  That  in  a  certain  proportion  of  cases  of  intracranial 
tumour  double  optic  neuritis  is  never  observed  throughout  the  whole 


DOUBLE  OPTIC  NEURITIS.  41 

course  of  the  case ;  and  that  in  others  it  has  either  not  developed, 
or  has  already  subsided,  when  the  case  comes  under  observation. 
Hence  the  absence  of  double  optic  neuritis  does  not  necessarily  ex- 
clude the  presence  of  a  tumour.  The  fact  that  there  is  no  double 
optic  neuritis  does,  however,  suggest  doubt;  and  unless  the  other 
symptoms  of  tumour  are  very  clearly  defined,  or  unless  tlie  physician 
feels  satisfied  that  there  is  no  other  condition  except  tumour  which 
could  reasonably  be  expected  to  account  for  the  phenomena  of  the 
case,  he  will  be  wise,  in  the  absence  of  double  optic  neuritis,  to  hesitate 
before  committing  himself  to  a  positive  diagnosis. 

In  those  cases  of  intracranial  tumour — and  I  agree  with  Dr. 
Buzzard  in  thinking  that  they  are  mostly  syphilitic — in  which  the 
double  optic  neuritis  subsides  under  treatment,  it  is  usually,  but  not 
always,  possible  to  say  from  the  condition  of  vision  and  the  state  of 
the  fundus  that  the  optic  discs  have  been  previously  inflamed. 

In  some  cases,  more  especially  when  the  optic  neuritis  is  recog- 
nised and  vigorously  treated  in  its  earlier  stages,  recovery,  both  as 
regards  vision  and  ophthalmoscopic  appearances,  may  be  perfect.  In 
others,  some  dimness  of  vision,  some  limitation  of  the  fields,  or  some 
changes  in  the  fundus,  such  as  white  lines  along  the  course  of  the 
vessels  or  white  patches  near  the  edge  of  the  disc,  remain.  In  other 
cases,  again,  marked  defects  in  vision  and  striking  ophthalmoscopic 
appearances  remain  behind. 

The  recognition  of  any  changes  in  the  fundus  indicative  of  past 
neuritis  is  in  some  cases  of  great  diagnostic  importance. 

Secondly.  That  double  optic  neuritis  may  occur  in  some  of  the 
conditions,  which  are  most  easily  mistaken  for  intracranial  tumour, 
and  in  which  the  difficulties  of  diagnosis  are  sometimes  very  great. 
Double  optic  neuritis  is,  for  example,  almost  always  present  in  lead 
encephalopathy ;  it  is  not  uncommon  in  meningitis  and  cerebral 
abscess ;  and  it  may  occur  in  Bright's  disease.  It  has  occasionally 
been  observed  in  association  with  uterine  or  ovarian  derangements, 
hypermetropia,  and  anaemia,  which,  when  complicated  with  hysterical 
or  other  nervous  symptoms,  may  under  such  circumstances  {i.e.,  when 
associated  with  double  optic  neuritis)  be  easily  mistaken  for  cases  of 
intracranial  tumour. 

But  while  double  optic  neuritis  is  unquestionably  of  the  greatest 


42  ANALYSIS  OF  INDIVIDUAL  SYMPTOMS. 

diagnostic  value  as  a  sign  of  intracranial  tumour,  it  must  be  remem- 
bered that,  even  when  associated  with  the  other  typical  (general) 
symptoms  of  cerebral  tumour,  and  even  with  symptoms  indicative  of 
a  local  lesion,  a  tumour,  properly  so-called,  is  not  always  found  after 
death.  Fortunately  for  diagnosis,  cases  of  this  kind  are  quite  excexj- 
tional  and  rare.  The  following,  which  occurred  in  the  practice  of  Dr. 
Hughlings  Jackson,  and  which  is  quoted  by  Dr.  Hilton  Fagge,  is  a 
case  in  point : — ^A  woman,  aged  thirty-four,  had  for  about  a  year  been 
subject  to  attacks  of  severe  headache  accompanied  with  vomiting ;  for 
three  months  she  had  been  blind.  Her  illness  began  with  vertigo  and 
momentary  unconsciousness,  after  which  she  had  headache  for  four 
days.  At  another  time  the  pain  lasted  for  three  weeks.  She  was 
admitted  into  hospital,  under  Dr.  Hughlings  Jackson's  care,  on 
December  19th,  1874.  On  January  6th,  1875,  she  had  an  attack  of 
pain  so  intense  as  to  make  her  toss  her  head  from  side  to  side,  hold- 
ing it  with  her  hands  and  saying,  "  Oh,  my  head,"  "  I  don't  know  what 
I  shall  do."  She  retched  and  vomited  frequently.  Both  optic  discs 
were  greatly  swollen,  and  the  veins  in  them  were  dilated  and  tortuous. 
After  the  10th,  she  sank  gradually  into  what  appeared  to  be  natural 
sleep,  which,  however,  passed  into  coma,  and  on  the  12th  she  died 
by  failure  of  the  respiration.  A  tumour  or  some  other  similar  lesion 
was  confidently  anticipated,  but  Dr.  Sutton,  who  made  the  autopsy, 
found  only  certain  microscopical  changes  in  the  substance  of  the  cortex. 

In  the  debate  on  optic  neuritis  which  took  place  at  the  Ophthal- 
mological  Society  a  few  years  ago.  Dr.  Hughlings  Jackson  stated — 
"  It  is  to  be  particularly  mentioned  that  optic  neuritis  is  found  in 
some  cases — clearly,  from  the  symptoms,  cases  of  intracranial  disease 
— where  ordinary  examination  (post  mortem)  discloses  no  local  disease 
within  the  cranium  or  in  any  other  part  of  the  body."  ^ 

Dr.  Stephen  Mackenzie  has  published  a  case  in  which  optic 
neuritis  occurred  in  connection  with  what,  at  the  post  mortem  exami- 
nation, appeared  to  be  simple  atrophy  of  the  brain ;  but  a  micro- 
scopical examination  of  the  cortex  of  the  brain  showed  a  diffused 
cerebritis  and  inflammation  extending  down  the  optic  nerve.  There 
was  no  meningitis  and  no  marked  effusion  into  the  optic  sheaths. - 

1  Transactions  of  the  Ophthalmological  Society  of  the  United  Kingdom,  vol.  i.,  p.  61. 

2  Brain,  vol.  vii.,  p.  257. 


OPTIC  ATROPHY.  43 

The  number  of  cases  of  intracranial  tumour  in  which  the 
neuritis  has  been  observed  on  one  side  only  is  too  small,  in  my 
opinion,  to  admit  of  any  very  definite  generalisation  being  made. 

O'ptic  AtfO'phy. — This  condition  is  sometimes  met  vsrith  in  long- 
continued  cases  of  intracranial  tumour.  It  usually  results  from 
previous  optic  neuritis ;  but  in  a  few  cases  it  is  primary,  and  may  then 
be  due  to  the  pressure  of  a  tumour,  or  of  the  dilated  cerebral 
ventricles,  upon  the  optic  chiasma  or  optic  nerve  trunk. 

In  some  cases  of  optic  atrophy  the  patient  is  completely  blind ; 
in  most,  both  the  acuity  of  vision  and  the  visual  field  are  markedly 
impaired.  When  the  atrophic  changes  are  very  slight — but  in  these 
it  is  difficult  or  impossible  to  recognise  any  distinct  alterations  in  the 
fundus  oculi  by  means  of  the  ophthalmoscope — the  acuity  of  vision 
(central  vision)  may  be  little  if  at  all  affected,  while  the  visual  field 
is  more  or  less  contracted.  Colour  vision  is  usually  impaired.  In 
post-neuritic  cases  the  contraction  of  the  visual  field  is  often  irregular 
in  outline. 

Now,  since  primary  atrophy  is  very  rarely  indeed  due  to  an 
intracranial  tumour,  while  post-neuritic  atrophy  is  common,  it  is  a 
point  of  some  diagnostic  importance  to  be  able  to  distinguish  the 
two  conditions.  There  are  cases  in  which  the  distinction  is  im- 
possible ;  but  in  the  majority  of  cases  in  which  the  atrophy  is  post- 
neuritic, some  indications  or  remains  of  the  previous  inflammation 
are  to  be  seen.  Indeed,  in  many  cases  the  inflammatory  changes 
(swelling  of  disc,  covering  up  of  the  vessels,  &c.)  can  still  be  recog- 
nised when  the  case  comes  under  observation.  But  even  in  long- 
continued  cases,  and  after  all  inflammatory  changes  have  subsided, 
the  appearance  which  the  disc  presents  enables  us  in  many  cases  to 
say  that  the  optic  atrophy  is  post -inflammatory  and  not  primary. 
Opaque,  chalky  whiteness  of  the  disc,  irregularity  or  indistinctness  of 
its  margins,  covering  up  of  the  origin  of  the  vessels,  the  presence  of 
white  lines  along  the  sides  of  the  vessels,  or  of  white  patches  on  the 
surrounding  retina,  and  the  fact  that  the  size  of  the  vessels  is  markedly 
different  from  the  normal,  are  in  favour  of  the  post -inflammatory 
character  of  the  atrophy. 


44  ANALYSIS  OF  INDIVIDUAL  SYMPTOMS. 

The,  Causation  of  the  DouhU  Optic  Neuritis  associated  with 
Intracranial  Tumours. 

The  causation  of  the  double  optic  neuritis,  which  is  so  frequently 
associated  with  intracranial  tumours,  has  given  rise  to  much  debate. 

Before  considering  the  different  theories  which  have  been  from 
time  to  time  advanced  to  account  for  its  production,  it  may  perhaps 
be  well  to  lay  down  certain  general  propositions,  with  which  most 
observers  will  probably  agree.     They  are  as  follows : — 

1.  Double  optic  neuritis  is  present  at  some  period  or  other  of  the 
course  of  the  great  majority  of  cases  of  intracranial  tumour. 

My  own  experience  with  regard  to  this  frequency  is  very  much  in 
accord  wdth  that  of  Gowers,  who  states  that  double  optic  neuritis  is 
present  in  about  eighty  per  cent,  of  the  cases  of  intracranial  tumour, 
at  some  period  or  other  of  their  course. 

2.  It  is  difficult  or  impossible  in  many  cases  to  distinguish  the 
papillitis  which  is  due  to  choking  of  the  disc,  from  that  which  is  due 
to  descending  neuritis. 

Most  observers  are  now  agreed  that  the  two  conditions  are  different 
degrees  of  one  and  the  same  process ;  in  other  words,  that  the  so- 
called  "  choked  "  disc  is  the  result  of  a  true  inflammatory  process,  and 
is  not  a  mere  oedema,  the  result  of  mechanical  compression. 

It  is  probable,  however,  that  the  papillitis  which  is  associated  with 
cerebral  meningitis  (and  which  is  presumably,  therefore,  a  typical 
descending  neuritis)  may,  in  some  instances  at  all  events,  be  distin- 
guished in  its  early  stages  from  the  papillitis  which  is  due  to  tumour. 
With  reference  to  this  point  Dr.  Gowers  says — "  Apart  from  the 
distinguishing  characters  afforded  by  the  degree  of  neuritis,  I  have 
only  noted  one  difference,  viz.,  that  during  the  early  stage  of  inflam- 
mation, when  it  is  coming  on  and  the  swelling  is  distmct,  the  papilla 
is  paler  in  meningitis  than  in  tumour."  ^ 

It  has  appeared  to  me  that  the  papillitis  of  tumour  is  more  fre- 
quently preceded  by  dilatation  of  the  retinal  veins  than  the  retinitis  due 
to  meningitis.  Gowers,  however,  with  his  much  larger  experience,  has 
come  to  a  different  conclusion.  He  states — "  In  tubercular  meningitis 
Garlick's  careful  observations  have  shown  that,  while  papillitis  is 

1    Transactions  of  the  Ophthalmological  Society  of  the  United  Kingdom,  vol.  i.,  p.  104. 


THE  CAUSATION  OF  DOUBLE  OPTIC  NEURITIS. 


45 


not,  fulness  of  the  veins  is,  related  to  an  increased  intracranial 
pressure.  In  the  course  of  a  descending  neuritis,  the  distention  of 
veins  may  be  very  great,  as  I  have  several  times  observed,  both  during 
life  and  after  death.  In  tumour  the  veins  at  first,  and  often  throuRh- 
out — when  the  neuritis  does  not  reach  a  considerable  decree  of 
intensity — are  little  above  the  normal  size,  and  present  no  tortuosities 
except  those  which  are  given  them  by  the  prominence  of  the  papilla. 
The  great  distention  of  the  veins  and  narrowing  of  the  arteries  occur 
when  the  inflammation  has  reached  a  certain  degree  of  intensity :  this 
points  to  the  neurotic  process  in  the  papilla  as  causing  strangulation 
by  pressure  in,  and  constriction  of,  the  vessels."  ^ 

The  papillitis  associated  with  tumour  is  as  a  rule  more  intense 
than  that  due  to  meningitis. 

3.  The  double  optic  neuritis  associated  with  tumour  is  a  "  general " 
and  not  a  "  localising  "  symptom ;  in  other  words,  it  may  be  due  to  a 
tumour  in  any  part  of  the  cranial  cavity.  It  may  result  from  a 
tumour  either  in  the  substance  or  on  the  surface  of  the  cerebrum, 
cerebellum,  or  pons  Varolii.  It  is,  however,  a  question  whether  double 
optic  neuritis  is  not  more  frequently  associated  with  tumours  in  some 
situations  than  in  others.  Thus  Drs.  Walter  Edmunds  and  I.  B.  Law- 
ford  state  that  in  an  analysis  of  ninety-six  cases  of  fatal  cerebral 
tumour,  they  found  optic  neuritis  was  present  in  eighty-six  per  cent,  of 
the  cases  in  which  the  new  growth  was  situated  in  the  basal  ganglia 
or  in  the  cerebellum,  but  in  only  forty-six  per  cent,  of  those  cases  in 
which  it  was  seated  at  the  convexity.  In  my  own  experience, 
tumours  of  the  convexity  are  more  frequently  associated  with  double 
optic  neuritis  than  these  statistics  show ;  but  I  am  quite  prepared  to 
allow  that  tumours  in  the  basal  ganglia  and  cerebellum  are  more 
likely  to  be  associated  with  papillitis  than  tumours  of  the  convexity, 
in  consequence,  I  think,  of  the  fact  that  they  more  frequently  pro- 
duce ventricular  dropsy,  great  increase  of  the  intracranial  pressure, 
and  their  results. 

Perhaps  tumours  of  the  medulla  oblongata  are  less  frequently 
attended  with  double  optic  neuritis  than  tumours  in  other  parts. 

With  regard  to  this  point  Dr.  Hughlings  Jackson  says — "  Like 
Gowers,  I  have  not   yet   seen    optic  neuritis  with    tumour   of  the 

^   Medical  Ophthalmoicopu,  Second  Edition,  p.  71. 


46  ANALYSIS  OF  lAWIVIDUAL  SYMPTOMS. 

medulla  oblongata ; "  but  he  adds,  "  I  should  say  that  I  have  only 
once  seen  tumour  limited  to  that  part,  and  forget  whether  there  was 
neuritis  or  not."  ^ 

If  it  is  the  case  that  tumours  of  the  medulla  oblongata  are  less 
frequently  associated  with  double  optic  neuritis  than  tumours  in  other 
parts  of  the  intracranial  cavity,  the  fact  may  perhaps  be  explained 
by  supposing  that  tumours  in  this  situation  seldom  attain  to  any 
gTeat  size,  and  that  they  are,  in  some  instances  at  all  events, 
unattended  with  ventricular  dropsy  or  any  great  increase  of  the 
intracranial  pressure. 

4.  Double  optic  neuritis  may  occur  in  connection  with  any  form 
of  new  growth.  It  is  associated  with  small  as  well  as  with  large 
tumours,  and  may  be  associated  with  almost  any  (pathological) 
variety  of  tumour. 

This  proposition  must,  however,  be  qualified  by  stating  that  slow- 
o-rowino-  tumours,  which  neither  produce  increased  intracranial 
pressure  nor  irritation  of  the  intracranial  contents,  may  be  un- 
attended with  optic  neuritis,  or,  indeed,  with  any  other  symptoms. 
Small  psammomata,  for  instance,  are  as  a  rule  completely  latent; 
and  even  tumours  of  a  larger  size,  such  as  that  which  was  found  in 
the  case  of  the  late  Professor  John  Hughes  Bennett,  may,  if  they 
fulfil  the  conditions  stated  above,  produce  no  disturbance. 

Vice  versa,  the  tumours  which  do  most  frequently  produce  double 
optic  neuritis  are  those  which  cause  either  increased  intracranial 
pressure,  or  irritation  of  intracranial  structures  (meningitis  or  cere- 
britis),  or  both. 

Presumably,  therefore,  in  one  or  other,  or  all  of  these  conditions, 
the  cause  of  the  double  optic  neuritis,  which  is  associated  with  intra- 
cranial tumours,  is  to  be  found  ;  and,  as  a  matter  of  fact,  these  three 
pathological  alterations  form  the  basis  of  three  of  the  theories  which 
liave  been  advanced  to  explain  its  causation,  viz. : — 
(1.)  The  increased  pressure  theory. 
(2.)  The  descending  neuritis  theory. 
(3.)  The  vaso-motor  irritation  theory. 

A  fourth  theory  is  that  which  supposes  that  some  irritant, 
produced  in  or  around  the  tumour,  becomes  mingled,  as  it  were,  with 

1  Transactions  of  the  OpMhalmoloykal  Society  of  the  United  Kingdom,  vol.  i.,  p.  79. 


THE  CAUSATION  OF  DOUBLE  OPTIC  NEURITIS.      47 

the  cerebro-spinal  fluid,  and  being  conveyed  by  it  into  the  subvaginal 
space  which  surrounds  the  orbital  portion  of  the  optic  nerve, 
produces  irritation  and  inflammation  of  the  nerve — in  other  words, 
double  optic  neuritis. 

Leber,  who  first  advanced  this  theory,  supposed  that  "  intra- 
cranial tumours,  as  also  tuberculosis,  give  rise  to  congestion  of  the 
vessels,  secretory  inflammation,  hydrops  ventriculorum,  and  increased 
pressure ;  and  that  the  products  of  tissue-change  of  those  neoplasms, 
which  become  mingled  with  the  inflammatory  transudations,  act  as 
an  inflammatory  stimulus,  and,  passing  with  the  cerebro-spinal  fluid 
into  the  intervaginal  space  of  the  optic  nerve,  as  far  as  the  eye,  give 
rise  there  to  neuritis  and  papillitis."  ^ 

Deutschmann,  who  adopts  Leber's  theory,  suggests  that  the 
irritating  elements  are  perhaps  micro-organisms,  which,  being  already 
present  in  the  system,  congregate  around  the  tumour  as  a  "  place  of 
least  resistance,"  and  are  thence  carried  to  the  optic  nerves  in  the 
manner  described  above. 

This  theory,  which  supposes  both  the  presence  of  an  irritant  in 
the  cerebro-spinal  fluid  and  increased  intracranial  pressure  (for 
Deutschmann  admits  that  the  increased  intracranial  pressure  is  a 
favouring,  though  he  thinks  it  is  not  an  essential  condition),  may  be 
termed  the  irritation-pressure  theory. 

I  may  at  once  say  that,  for  my  own  part,  I  think  it  probable  that 
the  double  optic  neuritis  of  intracranial  tumours  is  not  always  pro- 
duced in  the  same  manner. 

It  must,  I  think,  be  admitted  that  papillitis  may  be  due  to  a 
descending  inflammation  passing  from  the  brain  along  the  nerve,  or 
along  the  meninges  (connective  tissue  and  blood-vessels)  to  the  nerve  ; 
but  that  this  is  the  manner  in  which  it  is  usually  produced  in  cases 
of  tumour  is,  I  think,  by  no  means  proved. 

The  irritation-pressure  theory  of  Leber  and  Deutschmann  seems 
to  me  the  most  plausible  which  has  yet  been  advanced ;  but  before  it 
can  be  definitely  accepted,  the  presence  of  an  irritant  and  its  exact 
nature  require,  I  think,  further  demonstration. 

While  the  experiments  of  Deutschmann  would  appear  to  show 
that  increased  intracranial  pressure  ]3er  se  is  not  the  only  or  the 

^  Transactions  of  the  International  Medical  Congress,  1881,  vol.  hi.,  p.  57. 


48  ANALYSIS  OF  INDIVIDUAL  SYMPTOMS. 

essential  Ccaiise  of  papillitis,  I  am,  for  the  reasons  which  will  be 
presently  given,  of  opinion  that  it  is  a  factor  which  cannot  be 
ignored ;  and  that,  in  many  instances  at  all  events,  it  does 
play  an  important,  though  a  secondary,  part  in  the  production 
of  papillitis. 

Before  considering  the  different  theories  in  detail,  it  may  perhaps 
be  well  to  briefly  summarise  the  chief  post  mortem  appearances  in 
cases  of  intracranial  tumour  which  have  a  direct  bearing  upon  the 
question  under  discussion. 

In  the  great  majority  of  cases  there  is  evidence  of  increased  intra- 
cranial pressure;  flattening  of  the  convolutions,  effacement  of  the 
sulci,  and  in  many  cases  a  scanty  amount  of  sub-arachnoid  fluid. 

Dropsical  distention  of  the  ventricles  is  frequent. 

In  many  cases,  localised  meningitis,  cerebritis,  or  softening  is 
present  in  the  immediate  neighbourhood  of  the  tumour ;  and,  in  a  few 
cases,  there  is  evidence  of  localised  meningitis  in  other  parts  {i.e.,  in 
parts  at  a  distance  from  the  tumour,  and  which  have  no  apparent 
connection  with  the  new  growth).  Except  in  tubercular  cases, 
generalised  meningitis  is  rarely  found. 

The  vaginal  slieaths  surrounding  the  optic  nerves  are,  in  the 
majority  of  cases,  distended  with  fluid,  or,  if  collapsed  and  undis- 
tended,  appear,  from  their  flaccid  and  loose  condition,  to  have  been 
over-distended. 

In  many  instances,  in  which  microscopic  examination  shows  dis- 
tinct evidence  of  inflammatory  changes  in  the  papilla,  in  the  optic  nerve 
behind  the  eyeball,  and  in  the  fibrous  coverings  of  the  nerve,  these 
structures  appear  normal  to  the  naked  eye.  This  is  a  point  of  some 
practical  importance,  and  I  would  emphasise  the  fact  that  in  some 
cases,  in  which  well-marked  optic  neuritis  was  present  during  life,  I 
have  been  unable,  even  with  the  aid  of  a  pocket  lens,  to  satisfy  myself 
that  the  optic  papilla  was  distinctly  abnormal.  In  my  experience, 
microscopical  examination  is,  in  some  instances,  required  to  decide 
the  point. 

For  the  same  reason,  the  fact  that  there  is  no  naked-eye  evidence 
of  meningitis  within  tlie  cranial  cavity  is  not  perhaps  sufficient  to 
exclude  cerebral  meningitis.  It  is  possible  that  in  some  cases  of  intra- 
cranial tumour,  in  which  the  naked-eye  appearances  are  simply  those 


THE  CAUSATION  OF  DOUBLE  OPTIC  NEURITIS.      49 

of  increased  pressure,  the  microscope  may  show  some  evidences  of 
inflammatory  changes  in  the  meninges.  I  cannot,  however,  say  that 
my  own  observation  lends  any  definite  support  to  this  view. 

In  this  connection  it  is  important  to  note  that  in  many  cases  of 
intracranial  tumour  the  microscope  shows  diffuse  irritative  changes 
(in  the  form  of  proliferation  and  enlargement  of  the  connective  tissue 
elements — Deiter's  corpuscles),  not  only  in  the  immediate  neighbour- 
hood of  the  tumour,  but  more  or  less  widely  diffused  throughout  the 
swollen  brain  tissue.  Whether,  as  has  been  suggested,  this  diffuse 
irritative  change  is  a  cause,  or  the  cause,  of  the  optic  neuritis,  headache, 
and  other  general  (non-localising)  symptoms  of  intracranial  tumours,  is 
a  point  which  has  not  yet  been  definitely  determined.  But  it  is  im- 
portant to  note  that  cases  have  been  reported  by  Hughlings  Jackson, 
Stephen  Mackenzie,  and  Gowers,  in  which  optic  neuritis  was  associated 
with  headache,  vomiting,  and  all  the  typical  (general)  symptoms  of 
"  coarse  "  intracranial  disease,  and  in  which  an  atrophied  condition  of 
the  brain,  with  microscopic  appearances  indicative  of  a  diffuse  irri- 
tative change  in  the  nerve  centres,  but  no  tumour  or  other  "  coarse  " 
localised  lesion,  was  found  post  mortem. 

With  regard  to  the  microscopical  appearances  in  the  optic  nerve 
itself,  I  regret  that  I  am  unable  to  speak  as  definitely  as  I  would 
wish.  Although  I  have  examined  a  large  number  of  optic  nerves, 
both  in  cases  of  intracranial  tumour  and  in  other  conditions,  I  have 
failed  to  satisfy  myself  with  regard  to  many  of  the  points  at  issue. 
This  is  partly  due  to  the  fact  that  the  inherent  difficulties  connected 
with  the  subject  have  seemed  to  me  to  be  greater  than  some  writers 
appear  to  have  found  them ;  and  partly  to  the  circumstance  that  in 
most  instances  my  examination  has  been  limited  to  the  intra-orbital 
nerve,  and  that  I  have  not  examined  the  intracranial  portion  and  the 
optic  chiasma,  the  condition  of  which  has  an  important  bearing  on 
some  of  the  points  in  dispute.  Possibly,  too,  the  methods  of  prepara- 
tion which  I  have  employed  (hardening  in  Miiller's  fluid,  freezing, 
staining  with  picro-carmine  or  borax-carmine,  and  mounting  in 
Tarrant's  solution,  or  in  xylol  balsam)  are  not  the  most  satisfactory 
for  bringing  out  the  morbid  appearances,  but  they  are  those  with 
which  I  am  most  familiar,  and  with  which  I  was  in  the  habit  of 
working  when,  as   Pathologist  to   the   Edinburgh   Eoyal  Infirmary, 

D 


50 


ANALYSIS  OF  INDIVIDUAL  SYMPTOMS 


material  of  this  kind  came  in  my  way.     Embedding  in  celluloidin  is 
perhaps  preferable  to  the  freezing  method. 


Fig.  12. — Camera  lucida  drawing  of  a  section  through  the  optic  nerve  and 
surrounding  parts  in  a  case  of  glioma  of  the  cerebellum,  showing  well-marked 
papillitis.  There  is  great  swelUng  and  vascularity  of  the  optic  disc,  the 
presence  of  inflammatory  products  in  the  subvaginal  space,  and  swelling  of 
the  connective  tissue  trabeculse  surrounding  the  pial  sheath.  (From  a  pre- 
paration stained  with  picro-carmine,  cleared  v,dth  absolute  alcohol  and  oil  of 
cloves,  and  mounted  in  xylol  balsam. ) 

The  letter  C  points  to  the  centre  of  the  optic  papUla  ;  Z*  to  a  large  vessel 
which  is  distended  with  a  dense  mass  of  blood  corpuscles  ;  E  to  the  swoUen 
deeper  layers  of  the  retina  adjacent  to  the  disc  ;  F  to  the  deeper  layers  of 
the  retina  where  they  are  healthy  ;  G  to  the  choroid,  which  has  become  de- 
tached from  the  retina  and  sclerotic  ;  /  to  the  dural  sheath  of  the  optic 
nerve ;  A'  to  the  subvaginal  space,  which  is  distended  vrith  inflammatory 
products  right  up  to  its  termination,  L. 

The  case  is  reported  in  the  Edinburgh  Medical  Journal,  January  1887, 
p.  591. 

In  well-marked  cases  of  optic  neuritis,  the  microscopic  appearances 
in  the  papilla  itself  (swelling  of  the  nerve  fibres,  distention  of  the 


>: 


THE  CAUSATION  OF  DOUBLE  OPTIC  NEURITIS.       51 

capillaries  in  the  disc  and  of  the  large  vessels  of  the  adjacent  retina, 
abundant  infiltration  with  leucocytes,  and  in  some  instances  extrava- 
sations of  red  blood  corpuscles  and  even  hsemorrhages  of  some  size  in 
the  disc  itself,  or  in  the  surrounding  retina;  with,  in  some  cases, 
swelling  of  the  nerve  cells  of  the  adjacent  portions  of  the  retina)  are 
quite  distinctive  of  inflammation,     (See  Fig.  12.) 

In  such  cases  I  have,  like  Leber  and  Deutschmann,  usually  found 
nuclear  proliferation  and  engorgement  of  the  blood-vessels  in  the 
adjacent  portions  of  the  choroid. 

In  most  cases  of  well-marked  papillitis  which  I  have  examined, 
there  has  been  distinct  nuclear  proliferation  in  the  inner  and  outer 
sheath  of  the  nerve,  the  presence  of  corpuscular  elements  (leucocytes, 
and,  in  a  few  instances,  red  blood  corpuscles)  in  the  subvaginal  space, 
together  with  what  has  appeared  to  me  to  be  swelling  of  the  con- 
nective tissue  trabecul?e,  which  pass  across  the  vaginal  space  and  con- 
nect the  outer  with  the  inner  sheath.  I  have  considered  these 
appearances,  when  well  marked,  as  indicative  of  inflammation  (peri- 
neuritis), and  have  regarded  them  as  being  in  all  probability  the  cause 
of  the  papillitis.  But  whether  they  were  due  to  a  process  of  "  de- 
scending "  inflammation,  or  whether  they  were  caused  by  an  irritant 
being  forced  by  the  increased  intracranial  pressure  into  the  subvaginal 
space  (and  this  is  one  of  the  weak  points  in  my  observations),  I  have 
been  unable  to  decide. 

In  this  connection  I  may  state  that  I  have  in  several  instances 
observed  a  minor  degree  of  the  same  changes  in  cases  in  which  there 
was  neither  intracranial  tumour  nor  optic  neuritis  ;  and  I  am,  in  con- 
sequence, disposed  to  think  that  nuclear  proliferation  in  the  outer  and 
inner  sheaths  of  the  nerve  and  swelling  of  the  connective  tissue 
trabeculse  may  be  more  frequent,  and  consequently  of  less  importance 
as  a  sign  of  "descending"  inflammation,  than  some  observers 
appear  to  tliink. 

In  one  case  of  chronic  Bright's  disease  (the  cirrhotic  form)  in  which 
the  microscopical  examination  showed  distinct  evidence  of  papillitis, 
the  same  inflammatory  appearances  in  the  sheaths  of  the  nerve  and 
subvaginal  space  were  well-marked.  This  is  a  point  of  interest  when 
taken  in  connection  with  the  following  statement  which  Dr.  Broadbent 
made  in  the  discussion  at  the  Ophthalmological   Society  on  optic 


5  2  A NAL  YSIS  OF  INDl  VI D  UAL  S  YMFTOMS. 

neuritis.  In  speaking  in  support  of  the  increased  pressure  theory, 
he  stated — "  A  fact  of  great  weight,  which  had  only  come  under  his 
observation  comparatively  recently,  was  that,  in  the  optic  neuritis  of 
renal  disease,  the  same  distention  of  the  optic  sheath  was  at  times 
observed  as  in  the  intracranial  disease.  Now,  besides  the  headache, 
there  were  other  indications,  such  as  the  relief  of  uraemic  convulsions 
by  bleeding,  that  in  kidney  disease  there  was  increased  intracranial 
pressure—  due,  no  doubt,  to  high  arterial  tension — and  there  was  no 
clue  to  the  occurrence  of  optic  changes  in  one  case  of  kidney 
disease  aud  its  absence  in  another,  unless  it  were  to  be  found  in  the 
fact  that  he  had  never  yet  seen  them  where  the  arterial  tension  was 
not  excessive."  ^ 

In  well-marked  cases  of  papillitis  the  connective  tissue  trabecules 
and  the  nerve  fibres  of  the  lamina  cribrosa  have  appeared  to  me  to  be 
swollen,  and  I  am  unable  to  speak  in  the  same  positive  manner  that 
Gowers  does  as  to  the  absence  of  all  constriction  of  the  vessels  at  this 
point,  although  I  quite  admit  that  in  most  cases  the  constriction  is 
seated  in  the  swollen  papilla.  Gowers  says,  "  I  have  never  been  able 
to  discover  any  evidence  of  constriction  of  the  vessels  in  the  sclerotic 
ring  or  behind  it.  Their  calibre  here  is  always  uniform.  This  state- 
ment is  based  on  the  most  careful  search  for  any  evidence  of  such 
compression  in  a  number  of  cases  of  papillitis  from  various  intra- 
cranial diseases.  In  one  case  only  was  there  an  appearance  of 
narrowing,  and  in  this,  from  the  unaltered  course  of  an  adjacent 
vessel,  it  was  evidently  due  to  a  slight  alteration  in  the  position  of 
the  vessel  at  this  spot,  in  consequence  of  which  the  sections  ceased  to 
pass  through  its  widest  part.  It  is  always  in  front  of  the  sclerotic,  in 
the  substance  of  the  swollen  papilla,  that  the  vessels  present  con- 
spicuous constriction,  and  are  pressed  upon  and  have  their  walls 
thickened  by  new  tissue.  Further,  the  most  intense  strangulation 
may  occur  in  cases  in  which  there  is  reason  to  believe  that  there  is 
no  intracranial  disease  ;  and  in  case  27,  in  which  there  was  no 
intracranial  condition  that  could  cause  any  mechanical  effect,  the 
intra-ocular  signs  of  constriction  and  mechanical  congestion  were 
very  marked."  ^ 

*    Transactions  of  the  Ophthalmologieal  Society  of  the  United  Kingdom,  vol.  i.,  p.  110. 
-  Medical  Ophthalmoscopy,  Second  Edition,  p.  71. 


THE  CAUSATION  OF  DOUBLE  OPTIC  NEURITIS.      53 

With  regard  to  the  condition  of  the  optic  nerve  behind  the  papilla 
in  cases  of  well-marked  papillitis,  I  have  in  some  instances  found 
thickening  of  the  connective  tissue  trabeculse  and  excess  of  nuclei, 
more  especially  in  those  portions  of  the  nerve  adjacent  to  the  sheath. 
In  some  cases  these  appearances  have  been  slight,  in  fact  not  much 
greater  than  I  have  found  in  other  cases  in  which  there  was  neither 
intracranial  tumour  nor  papillitis.  And  in  this  connection  I  would 
ask,  what  degree  of  trabecular  thickening  and  nuclear  proliferation  is 
indicative  of  inflammation  (neuritis)  ?  When  these  appearances  are 
little  marked,  I  have  felt  considerable  difficulty  in  deciding  that  they 
were  distinctly  inflammatory.  In  several  instances,  in  which  there 
was  no  papillitis,  and  no  reason  to  suspect  inflammatory  change  in 
the  nerve  trunk  behind  the  papilla,  I  have  found  a  degree  of 
trabecular  thickening  and  nuclear  excess  which  has  appeared  to  me  to 
be  excessive,  and  which  would,  I  suspect,  by  some  observers  (if  they 
were  examining  cases  of  papillitis)  be  considered  as  indicative  of  a 
descending  neuritis. 

One  of  the  most  typical  cases  of  inflammation  of  the  optic  nerve 
behind  the  papilla  which  has  come  under  my  observation  was  a  case 
of  myxoedema.  In  that  case,  bright  staining  nuclei  (leucocytes)  were 
thickly  scattered  throughout  the  whole  thickness  of  the  nerve,  and 
the  minute  blood-vessels  in  the  trunk  of  the  nerve  behind  the  eyeball 
were  dilated  and  engorged  with  blood.  In  no  cases  of  papillitis  due 
to  intracranial  tumour  have  I  seen  such  intense  neuritis  in  the  post- 
ocular  portion  of  the  nerve  as  in  this  case. 

Let  us  now  briefly  consider  these  different  theories  more  in  detail, 
and  in  considering  this  part  of  the  subject  a  certain  amount  of 
repetition  is,  I  fear,  unavoidable. 

The  Increased  Pressure  and  Increased  Pressure-irritation  Theories. 

Von  Graefe,  who  was  the  first  to  recognise  and  direct  attention  to 
the  frequent  occurrence  of  papillitis  or  "  choked  "  disc  (stauungs- 
papille,  as  he  termed  it)  in  cases  of  intracranial  tumour,  supposed 
that  it  was  distinct  from  the  descending  optic  neuritis  which  results 
from  cerebral  meningitis  ;  and  that  it  (the  stauungspapille)  was  the 
result  of  increased  intracranial  pressure  exerted  on  the  cavernous 
sinus,  with  consequent  obstruction   of  the  venous  return  from  the 


54  ANAL  YSIS  OF  INDIVID  UAL  S  YMPTOMS. 

orbit.      This   obstruction    to   the   venous   return   was,   he   thought, 
intensified  by  the  unyielding  character  of  the  sclerotic  ring. 

This  theory  was  abandoned  when  it  was  shown  that  the  communi- 
cation between  the  superior  ophthalmic  and  the  anterior  facial  veins 
is  so  free  that  even  complete  obstruction  of  the  cavernous  sinus  does 
not  produce  venous  stasis  and  oedema  in  the  optic  papilla. 

Modifications  of  the  increased  intracranial  pressure  theory  were 
subsequently  advanced,  when  it  was  shown  that  the  subvaginal  space 
surrounding  the  optic  nerve  is  continuous  with  the  subarachnoid 
space  m  the  cranial  cavity,  and  further  (though  the  correctness  of 
this  supposed  anatomical  fact  is  denied  by  Leber)  that  coloured 
liquids  injected  into  the  cranial  cavity  not  only  find  their  way  into 
the  subvaginal  space  surrounding  the  nerve,  but  also  (presumably 
through  the  lymph  spaces  in  the  optic  nerve  and  lamina  cribrosa)  into 
the  fundus  oculi. 

These  modifications  of  the  increased  intracranial  pressure  theory 
suppose  that,  as  a  result  of  the  increased  intracranial  pressure,  which 
is  so  frequently  present  in  cases  of  intracranial  tumour,  fluid  is  forced 
into  the  subvaginal  sheath,  which  becomes  over-distended  ;  and  that 
the  papillitis  is  due  either  to  [ct)  the  venous  stasis  which  results  from 
compression  of  the  optic  nerve  and  its  vessels  by  the  fluid  in  the 
over-distended  sheath,  or  (&)  lymphatic  engorgement.  Schmidt 
believed  that  the  neuritis  was  not  the  result  of  mere  compression  of 
the  optic  nerve,  but  that  it  was  perhaps  due  to  irritation,  exercised 
by  fluid  forced  into  the  lymph  spaces. 

In  opposition  to  these  modifications  of  the  increased  pressure 
theory,  it  has  been  argued  (1)  that  in  some  cases  of  intracranial 
tumour,  in  which  there  is  marked  post-mortem  evidence  of  increased 
intracranial  pressure,  there  is  no  neuritis ;  (2)  that  in  some  cases  of 
intracranial  tumour  in  which  there  is  no  increased  intracranial 
pressure  there  is  neuritis  ;  (3)  that  optic  neuritis  occurs  in  connection 
with  small  localised  tumours  as  well  as  with  voluminous  new 
growths  ;  (4)  that  in  some  of  the  cases  in  which  there  is  neuritis 
there  is  no  distention  of  the  vaginal  sheaths  ;  (5)  that  neuritis  is  met 
with  in  conditions  of  cerebral  atrophy,  or  rather  with  a  wasted  brain 
in  which  there  are  diffuse  irritative,  microscopical  changes  ;  (6)  that 
in  chronic  hydrocephalus,  in  which  there  is  great  increase  of  the 


THE  CAUSATION  OF  DOUBLE  OPTIC  NEURITIS.      55 

intracranial  pressure,  neuritis  is  rarely  seen  ;  (7)  that  in  cerebral 
hsemorrhage,  with  increased  pressure,  neuritis  does  not  occur ;  (8)  that 
in  the  rare  cases  of  cerebral  tumour  in  which  neuritis  is  limited  to 
one  eye,  it  occurs  in  the  eye  on  the  opposite  side  to  the  brain  lesion  ; 
(9)  that  the  lymph  spaces,  which  are  supposed  to  pass  from  the  sub- 
vaginal  space  into  the  optic  nerve,  do  not  exist  (Leber) ;  and  (10)  that 
experimentally  produced  increased  pressure  within  the  cranial  cavity 
and  vaginal  sheath  does  not  produce  neuritis. 

The  last  argument  which  Deutschmann  has  advanced,  and  which  is 
based  on  an  elaborate  series  of  experiments,  seems  to  me  by  far  the 
most  convincing.^ 

His  experiments  were  made  with  the  object  of  determining  the 
following  points.  (I  quote  from  the  very  full  abstract  of  his  work 
published  in  the  OiMlialmic  Bevuw,  April  1887.) 

"  (1.)  What  degree  of  hydrops  of  the  optic  nerve  in  animals  is 
required  to  produce  changes  in  the  disc  similar  to  those  of  the  choked 
disc  in  man  ? 

"  (2.)  Are  there  any  conditions  under  which  a  moderate  and  even 
transient  dropsy  of  the  nerve,  such  as  is  found  post  mortem  in  man, 
is  associated  with  the  occurrence  of  choked  disc  ? 

"For  the  determination  of  the  first  question,  he  made  injections 
directly  into  the  nerve  sheath.  Dividing  the  superior  rectus,  he  laid 
bare  and  cut  through  the  optic  nerve  in  front  of  the  optic  foramen ;  then 
drawing  forward  the  distal  end,  and  taking  special  care  not  to  rupture 
the  central  vessels  at  their  entrance  into  the  nerve  trunk,  he  injected 
warm  sterilised  agar-agar  solution,  the  advantage  of  which  is  that  at 
the  body  temperature  it  remains  of  a  soft  semi-iluid  consistence,  and 
is  only  very  slowly  absorbed.  A  ligature  being  then  applied  to  the 
nerve,  the  divided  muscle  was  sutured,  and  the  wound  closed ;  the 
whole  with  antiseptic  precautions.  Healing  followed  almost  without 
trace  of  the  operation.  By  filling  the  nerve  sheath  very  forcibly, 
he  obtained  ophthalmoscopic  evidence  of  a  total  arrest  of  circulation 
in  the  retina,  and  a  few  hours  later  a  swelling  and  turbidity  of  the 
papilla  much  resembling  the  choked  disc  in  man.  Microscopic 
sections  showed  a  well-marked  compression  of  the  nerve  close  to  the 
globe,  swelling  and  cedema  of  the  papilla,  and  so  forth,  but  no  trace  of 

^  Ueber  Neuritis  Optica,  von  Prof.  R.  Deutschmann,  1887. 


56  ANAL  YSIS  OF  INDl  VI D UAL  S  YMPTOMS. 

true  neuritis  and  perineuritis.  When  the  injection  was  less  forcible, 
however,  though  still  sufficing  to  produce  a  more  marked  hydrops  than 
is  usually  found  in  the  human  subject,  he  obtained  only  a  temporary 
diminution  of  the  arteries  and  an  over-filling  of  the  veins ;  moreover, 
these  vascular  changes  disappeared  in  an  hour  or  two,  and  micro- 
scopic examination  several  days  later  showed  no  trace  of  pathological 
change  either  in  the  nerve  or  the  papilla. 

"  Deutschmann  concludes  that  in  animals  a  choldng  of  the  disc 
comparable  with  that  which  occurs  in  man  can  only  be  produced  by 
pressure  sufficient  in  amount  to  arrest  the  circulation.  No  one,  he 
points  out,  has  found  a  degree  of  hydrops  in  the  human  optic  nerve 
approaching  to  this  required  amount ;  no  one  has  found  a  condition 
of  simple  oedema  without  trace  of  commencing  inflammation ;  no  one 
has  seen  evidence  of  actual  compression  of  the  nerve  ;  moreover,  the 
frequent  retention  of  good  vision  in  such  cases  refutes  the  idea  of 
an  arrested  circulation. 

"  In  the  next  place,  Deutschmann  made  injections  into  the  cranial 
cavity  in  order  to  fill  the  nerve  sheath  by  means  of  an  excess  of 
pressure  within  the  skull.  He  used  agar-agar,  coloured  with  Indian 
ink,  and  rendered  fluid  by  warmth.  He  repeated  the  injections  from 
time  to  time  in  the  same  animal,  and  employed  strictly  antiseptic 
measures.  He  thus  established  not  merely  a  transient  excess  of 
pressure  in  the  skull,  but  one  which  was  renewed  from  time  to  time ; 
and  by  the  antisepsis  he  obtained  the  effects  of  pressure  without 
inflammatory  complication.  A  well-marked  injection  of  the  optic 
nerve  sheaths,  fully  equal  in  degree  to  that  which  is  found  in  the 
human  subject  under  conditions  of  morbid  pressure  in  the  cranium, 
and  lasting  for  several  weeks,  was  produced.  Dissection  showed  tliat 
the  sheath  was  forcibly  distended,  but  that  the  papilla,  the  nerve  trunk, 
and  its  sheaths  were  absolutely  free  from  any  trace  of  inflammation. 

"  From  these  experiments  Deutschmann  concludes  that  an  excess 
of  intracranial  pressure,  with  distention  of  the  optic  nerve  sheath, 
does  not  of  itself  suffice  to  produce  the  choked  disc.  The  transient 
vascular  changes  visible  after  each  rise  of  pressure  cannot  be  regarded 
as  the  first  stage  of  the  morbid  process  in  question." 

It  may  perhaps  be  doubted  whether  the  increased  intracranial  and 
intravaginal  pressure,  which  Deutschmann  produced  in  the  manne  r 


THE  CAUSATION  OF  DOUBLE  OPTIC  NEURITIS.      57 

described  above,  is  exactly  comparable  with,  and  could  be  expected  to 
be  attended  with  the  same  results  as  the  increased  pressure  due  to 
a  growing,  organised,  living  tissue  material,  such  as  a  tumour.  But  be 
that  as  it  may,  these  experiments,  to  my  mind,  afford  by  far  the  most 
striking  evidence  which  has  yet  been  advanced  against  the  simple 
increased  pressure  view. 

That  increased  intracranial  pressure  does  play  an  important, 
though  it  would  appear  from  Deutschmann's  experiments  a  secondary, 
part  in  the  production  of  papillitis  in  many  cases  of  intracranial 
tumour,  I  am  nevertheless  still  firmly  of  opinion. 

So  far  as  my  experience  enables  me  to  judge,  the  signs  of  increased 
pressure  are  very  generally  found  post  mortem. 

The  absence  of  papillitis  in  some  cases,  in  which  there  is  well-marked 
evidence  of  increased  pressure  after  death,  can  perhaps  be  explained 
by  supposing  that  there  is  some  mechanical  impediment  to  the  dis- 
tention of  the  vaginal  sheaths,  possibly  due  to  the  pressure  of  the 
enlarged  and  swollen  brain,  or  produced  in  some  other  manner ;  or, 
if  there  are  lymph  spaces  passing  from  the  vaginal  space  into  the 
optic  nerve  and  papilla,  to  the  presence  of  some  obstruction — such  as 
thickening  due  to  a  former  inflammation  of  the  sheaths  of  the  nerve — 
to  the  passage  of  the  subvaginal  and  irritant-carrying  fluid. 

The  fact  that  in  cases  of  cerebral  tumour  (such,  for  example,  as 
cerebral  syphilis)  a  neuritis  which  has  disappeared  under  treatment 
very  rarely  indeed  returns,  even  although  the  cerebral  lesion  should 
take  on  fresh  development,  seems  to  lend  support  to  this  view,  and  it 
is  to  my  mind  an  important  argument  against  the  "  descending  " 
neuritis  theory. 

Again,  I  agree  with  Broadbent  in  thinking,  that  the  fact,  that  in 
those  rare  cases  in  which  a  cerebral  tumour  is  associated  with  uni- 
lateral neuritis,  the  ocular  affection  has  always  been  found  on  the 
opposite  side  to  the  brain  lesion,  instead  of  being  in  favour,  as  Stephen 
Mackenzie  thinks,  of  a  "  descending  "  inflammatory  process,  can  only 
be  explained  by  supposing  that  there  was  some  mechanical  impedi- 
ment to  the  entrance  of  fluid  into  the  vaginal  space,  such  as  might 
be  caused  by  the  pressure  of  the  swollen  cerebral  hemisphere  in  which 
the  tumour  is  situated.  The  fact  that  the  decussation  in  the  chiasma 
is  incomplete  would,  in  my  opinion,  necessitate  a  "  descending  "  in- 


S8  ANALYSIS  OF  INDIVIDUAL  SYMPTOMS. 

flammation  being  carried  (granting,  of  course,  that  the  infiamraation 
was  a  true  neuritis,  descending  along  the  nerve  fibres)  to  hotli  discs, 
rather  than  to  the  disc  on  the  opposite  side  only.  With  reference  to 
this  point,  and  to  the  absence  of  papillitis  in  some  cases  of  tumour  in 
which  there  is  increased  intracranial  pressure,  the  following  statement, 
made  by  Dr.  Broadbent  at  the  debate  on  optic  neuritis,  is  of  import- 
ance : — "  It  should  be  remembered,"  he  said,  "  that  not  only  pressure 
but  fluid  was  requisite,  and  in  some  cases,  especially  with  large 
efl'usion  into  the  ventricles,  all  fluid  was  squeezed  out  of  the  mem- 
branes, and  the  surface  of  the  brain  was  dry  and  sticky.  Again,  the 
fluid  might  be  prevented  from  entering  the  optic  sheath,  and  he  had 
been  struck  by  two  cases  of  cerebral  tumour  with  hemiplegia,  men- 
tioned by  Dr.  Jackson,  in  which  there  had  been  unilateral  optic 
neuritis  in  the  eye  of  the  paralysed  side,  the  unaffected  eye  being  on 
the  same  side  as  the  tumour.  He  had  had  a  similar  case,  which  he 
had  previously  thought  stood  alone,  and  the  tumour  had  apparently 
excluded  the  fluid  from  the  optic  sheath  of  that  side."  ^ 

Again,  I  would  ask,  is  it  not  the  fact  that  in  most  of  the  cases  of 
intracranial  tumour  in  which  optic  neuritis  is  absent  there  is  little  or 
no  evidence  of  increased  pressure  ?  My  own  observations  would  cer- 
tainly lead  me  to  suppose  that  this  is  so.  And  if  it  is  a  fact,  it  seems 
to  me  to  be  strongly  in  favour  of  the  view  that  increased  pressure 
does  exercise  an  important  influence  in  the  production  of  papillitis. 
In  the  Edinburgh  Medical  Journal  for  January  1887,  I  have  reported 
two  cases  of  glioma  with  hsemorrhagic  extravasations  and  the  forma- 
tion of  large  cysts.  In  the  one,  which  was  situated  in  the  left  frontal 
lobe,  there  was  no  increase  of  intracranial  pressure  and  no  neuritis ; 
in  the  other,  which  was  situated  in  the  cerebellum,  there  was  great 
increase  of  the  intracranial  pressure  and  intense  neuritis.  The  tumour 
in  the  frontal  lobe  was  eminently  an  irritative  lesion,  for  it  had,  by  a 
process  of  direct  infection,  extended  across  the  anterior  median  fissure 
to  the  surface  of  the  opposite  hemisphere  of  the  brain.  In  these  two 
cases  the  only  factor  which  could  account  for  the  production  of 
neuritis  in  the  one  case,  and  its  absence  in  the  other,  was  increased 
pressure  ;  for  if  an  irritant  produced  by  the  tumour  metabolism  was 

^   Transactions  of  the  Ophthalmological  Society  of  the  Uiiited  Kingdom,  vol.  i.,  p.  110. 


THE  CA  USA  TION  OF  DO  UBLE  OPTIC  NE  URITIS.      5  9 

the  only  cause  of  optic  neuritis,  papillitis  should  have  been  present  in 
the  former  of  these  cases,  as  it  was  in  the  latter. 

It  is  because  the  Leber-Deutschmann  theory  recognises  the  im- 
portance of  increased  intracranial  pressure,  as  well  as  the  presence  of 
an  irritant,  that  I  think  it  affords  the  most  reasonable  explanation  in 
the  majority  of  cases. 

The  fact  that  optic  neuritis  may  be  associated  with  small  as  well 
as  with  large  tumours  is  probably,  in  some  instances  at  all  events,  due 
to  the  circumstance,  pointed  out  by  Broadbent,  that  "intracranial 
pressure  is  not  produced  by  the  tumour,  but  by  the  effusion  set  up  by 
it,  and  that  this  may  be  quite  as  abundant  when  the  tumour  is  small 
as  when  it  is  large,  while  a  large  tumour  may  devour  the  brain  sub- 
stance as  it  grows."  ^  The  absence  of  neuritis  in  hydrocephalus  is 
probably  best  explained  by  the  absence  of  an  irritant  in  the  subarach- 
noid fluid,  or  perhaps  in  those  cases  in  which  the  fontanelles  are  not 
closed,  by  the  relief  of  pressure  which  is  afforded  by  the  yielding  of 
the  bones  of  the  skull. 

The  fact  that  tumours  which  directly  press  upon  the  chiasma 
(and  are  therefore  likely  to  press  upon,  flatten,  and  prevent  distention 
of  the  vaginal  sheaths)  are  in  some  instances  attended  with  optic 
atrophy,  which  is  not  preceded  hy  papillitis  {i.e.,  primary  atrophy),  is 
also  perhaps  an  argument  in  favour  of  the  increased  pressure  rather 
than  of  the  descending  neuritis  theory. 

In  speaking  of  the  distention  of  the  nerve  sheath,  Gowers,  who  is 
an  advocate  of  the  descending  neuritis  rather  than  of  the  increased 
pressure  theory,  says: — "This  condition  is  so  frequently  associated 
with  optic  neuritis,  that  it  cannot  be  altogether  without  significance, 
although  we  may  not  be  disposed  to  accept  the  theory  of  Schmidt- 
Kimpler,  who  sees  in  it  the  essential  cause  of  the  affection  of  the 
papilla.  The  facts  that  optic  neuritis  may  occur  without  distention 
of  the  sheath,  and  that  the  latter  may  occur  without  the  former,  make 
it  difficult  to  recognise  a  necessary  casual  relation  between  the  two. 
Whatever  the  origin  of  the  distention  of  the  sheath,  we  must  re- 
gard it,  however,  as  exerting  an  influence  on  the  neuritis,  and  it 
seems  probable  that  under  certain  circumstances  it  may  be  the  sole 
cause.     Not  long  ago  I  made  a  post-mortem  examination  on  a  child, 

^  Medical  Ophthalmoscopy,  Second  Edition,  p.  110. 


6o  ANALYSIS  OF  INDIVIDUAL  SYMPTOMS. 

ten  years  of  age,  who  was  admitted  into  the  University  College 
Hospital  with  acute  cerebral  symptoms,  the  exact  nature  of  which 
was  obscure.  An  ophthalmoscopic  examination,  however,  showed  in- 
tense double  optic  neuritis,  with  great  swelling,  large  haemorrhages, 
and  extreme  distention  of  the  veins.  There  were  also  several  spots 
of  choroidal  damage,  characteristic  of  inherited  syphilis.  In  a  few 
days  the  child  died ;  we  found  an  extensive  cerebral  liEcmorrhage,  and 
many  of  the  arteries  presented  well-marked  syphilitic  disease.  There 
was  no  lesion,  however,  which  could  be  regarded  as  a  cause  of  the  optic 
neuritis.  But  the  orbital  plates  of  the  frontal  bone  were  thickened 
to  five  or  six  times  the  normal,  and  the  optic  foramina  were  much 
narrowed.  The  sheaths  of  the  optic  nerves  were  enormously  dis- 
tended, and  to  the  narrowing  of  the  foramina  and  distention  of  the 
sheaths  the  optic  neuritis  was  apparently  due."  And  again  he 
states,  "  In  all  cases  in  which  distention  of  the  optic  sheath  occurs  it 
probably  intensifies  the  inflammation,  however  arising."  ^ 

The  facts  that  neuritis  occurs  in  some  cases  of  intracranial  tumour 
in  which  there  is  no  increased  intracranial  pressure,  and  no  distention 
of  the  sheath,  and  indeed  in  some  cases  of  cerebral  atrophy  with 
diffuse  irritative  changes,  only  show  that  optic  neuritis  may  be  pro- 
duced by  other  causes  than  increased  pressure — a  point  which  I  fully 
allow.  These  facts  do  not  prove  that  increased  pressure  is  of  no  im- 
portance in  those  cases  of  intracranial  tumour — and  they  are  the 
majority — in  which  it  does  occur. 

Again,  as  Broadbent  argues,  in  cerebral  haemorrhage  there  is  not 
the  persistent  high  pressure  that  there  is  in  most  cases  of  tumour ; 
and  to  this  I  would  add  that  in  those  cases  in  which  the  cerebral 
hcemorrhaoje  is  so  larsje  as  to  Qive  rise  to  great  increase  of  the  intra- 
cranial  pressure,  the  case  is  usually  fatal,  and  there  is  therefore  no 
time  for  optic  neuritis  to  be  developed. 

Again,  in  some  rare  cases  of  hemorrhagic  extravasation  at  the 
base  of  the  brain,  in  which  presumably  blood  makes  its  way  into 
and  distends  the  vaginal  sheaths,  optic  neuritis  may  be  developed. 
This  is  certainly  very  rare.  I  have  reported  a  case  of  this  kind,  in 
which  intense  neuritis,  rapidly  followed  by  total  loss  of  vision,  was 
produced  at  such  an  early  stage  as  to  suggest  that  the  extravasated 

*  Medical  Ophthalmoscojpr/,  Second  Edition,  pp.  106  and  108. 


THE  CAUSATION  OF  DOUBLE  OPTIC  NEURITIS.      6i 


blood  had  made  its  way  from  the  base  of  the  brain  into  the  vaginal 
sheaths,  and  had  interfered  with  the  functions  of  the  optic  nerve  and 


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62  ANALYSIS  OF  INDIVIDUAL  SYMPTOMS. 

produced  the  papillitis,  partly  by  direct  pressure  and  partly  by 
excitiug  inflammatory  changes  in  its  immediate  neighbourhood. 
That  the  papillitis  might  have  been  produced  in  this  case  by  a 
"  descending  "  neuritis,  must  of  course  be  allowed ;  but  it  is,  I  think, 
more  difficult  to  account  in  this  way,  than  in  the  manner  which  has 
been  suggested  above,  for  the  fact  that  vision  was  so  completely  lost 
at  such  an  early  stage  of  the  case,  and  for  the  early  occurrence  of 
such  intense  papillitis. 

That  blood  which  is  extravasated  at  the  base  of  the  brain  may 
find  its  way  into  the  vaginal  sheaths,  and  may  produce  inflammatory 
changes,  is  shown  by  another  case  (rupture  of  an  aneurism  at  the 
base  of  the  brain)  which  I  have  reported  in  the  same  journal, ^  and  a 
microscopic  section  of  which  is  represented  in  Fig.  13, 

The  important  influence  which  some  forms  of  pressure  have  on 
the  production  of  optic  neuritis  is  also  shown  by  "  a  case  of  Mr. 
Lawson's  "  (quoted  by  Hilton  Fagge),  "  in  which  the  presence  of  a 
hydatid  cyst  within  the  orbit  caused  an  extreme  state  of  "  choked 
disc  ;"  four  days  after  puncture  of  the  tumour  the  engorgement  was 
found  to  have  almost  entirely  disappeared.  ^  The  same  rapid  subsidence 
of  the  optic  atrophy  may  also  follow  the  evacuation  of  a  cerebral  abscess. 

For  all  these  reasons,  then,  I  am  disposed  to  think  that  increased 
intracranial  pressure  is  in  many  cases  an  important  factor  in  the  pro- 
duction of  the  double  optic  neuritis  in  cases  of  intracranial  tumour ; 
though  I  am  not  prepared  to  assert  that  ]jer  se  it  is  the  ■  primary  or 
the  sole  and  sufBcient  cause  of  the  condition. 

The  Vaso-motor  Theory. 

Dr.  Hughlings  Jackson  lends  the  great  weight  of  his  authority  to 
this  theory,  which  supposes  that  the  tumour  induces  changes  in  the 
grey  matter  of  the  brain  in  its  neighbourhood,  and  that  these  altera- 
tions in  the  cerebral  grey  matter,  cause,  through  the  vaso-motor 
nerves,  vascular  changes  in  the  optic  discs,  which  result  in  inflamma- 
tion—  in  other  words,  in  optic  neuritis.  In  the  debate  at  the 
Ophthalmological  Society  Dr.  Hughlings  Jackson  said — and,  so  far  as 
I  know,  he  still  adheres  to  the  opinion  which  he  then  expressed — 

1  Edinburgh  Medical  Journal,  August  1886,  p.  97. 
-   Principles  and  Practice  of  Medicine,  vol.  i.,  p.  520. 


THE  CAUSATION  OF  DOUBLE  OPTIC  NEURITIS.     63 

"  The  hypothesis  which  semis  to  me  most  jylausiUe  when  the  whole  of 
the  non-localising  symptoms,  and  such  conditions  of  the  centres  as 
epileptiform  seizures  imply,  are  taken  into  account,  is  that  optic 
neuritis  results  doubly  indirectly  from  vaso-motor  action.  I  think," 
he  said,  "  that  optic  neuritis  may  be  a  doubly  indirect  result  of  local 
gross  organic  disease :  that,  first,  there  are  changes  of  instability 
about  the  tumour ;  that  next  these  lead  on  to  discharges,  by  inter- 
mediation of  vaso-motor  nerves,  to  repeated  contractions,  with  subse- 
quent paralysis  of  vessels  of  the  optic  nerves  or  centres,  and  then,  at 
length,  to  that  trouble  of  nutrition  which  is  optic  neuritis.  I  repeat 
that  such  induced  changes  are  causes  of  spasm  of  big  muscles.  More- 
over, in  cases  of  epilepsy  proper,  we  see  often  enough  effects  produced 
by  discharges  in  arteries  and  in  viscera,  as  well  as  convulsions  by 
discharges  in  big  muscles." 

The  following  facts  and  arguments  seem  to  negative  the  vaso- 
motor theory : — 

(1.)  As  Gowers,  Leber,  and  others  have  argued,  it  is  doubtful  if 
vaso-motor  alterations  can  or  do  produce  true  inflammatory  changes. 

(2.)  The  vaso-motor  nerves,  which  are  supposed  to  be  concerned  in 
the  production  of  optic  neuritis  in  the  manner  described  above,  and 
which  (since  tumours  in  all  parts  of  the  cranial  cavity  are  attended 
with  neuritis)  must  be  distributed  to  all  parts  of  the  cerebral  tissue, 
have  never  been  demonstrated. 

(3.)  Other  irritations  of  the  cerebral  tissue,  such  as  those  which 
are  produced  in  the  neighbourhood  of  liEemorrhagic  extravasations, 
patches  of  softening,  &c.,  do  not  produce  optic  neuritis. 

(4.)  If  optic  neuritis  can  be  produced  in  this  way  {i.e.,  by  vaso- 
motor irritation),  inflammatory  changes  ought  also  to  be  produced  in 
the  internal  ear  and  in  the  areas  of  distribution  of  the  other  cerebral 
nerves.  (This  point  will  be  more  fully  discussed  in  connection  with 
the  descending  neuritis  theory.) 

The  Descending  Neuritis  Theory. 

This  view,  which  supposes  that  inflammatory  changes  make  their 
way  downwards  from  the  cranial  cavity  to  the  optic  nerve  and  optic 
papilla,  either  (1.)  through  the  membranes,  blood-vessels,  and  connec- 
tive tissue,  or  (2.)  through  the  optic  nerve  itself,  has  much  to  be  said 


64  ANALYSIS  OF  INDIVIDUAL  SYMPTOMS. 

in  its  favour.  That  optic  neuritis  may  be,  and  frequently  is,  pro- 
duced in  this  manner,  every  one  will,  I  presume,  allow;  and  that 
optic  neuritis  associated  with  some  intracranial  tumours  is  produced 
by  such  a  descending  inflammation  I  am  fully  prepared  to  admit ;  but 
I  am  not  convinced  that  this  is  its  usual  or  most  common  cause. 

Many  of  the  arguments  which  have  been  previously  advanced  in 
favour  of  the  view  that  increased  pressure  is  an  important  factor 
in  the  production  of  papillitis  are  more  or  less  opposed  to  the 
descending  neuritis  view. 

All  these  arguments  need  not  be  again  repeated,  but  the  following 
are  some  of  the  chief  : — 

(1.)  In  many  cases  of  intracranial  tumour  in  which  well-marked 
papillitis  was  present  during  life,  there  is  absolutely  no  appearance  of 
meningitis  after  death. 

This  statement  applies  to  the  naked-eye  appearances.  Whether 
under  such  circumstances  inflammatory  changes  can  be  demonstrated 
by  means  of  the  microscope  I  am  not  prepared  to  say ;  but  in  some 
instances  in  which  I  have  examined  the  condition  of  the  membranes 
at  the  base,  and  indeed  in  other  parts  of  the  cerebrum,  I  have  failed 
to  satisfy  myself  that  such  inflammatory  changes  were  present. 

(2.)  Deutschmann  argues  that  it  is  doubtful  if  the  inflammatory 
changes  which  have  been  found  in  the  optic  nerve  are  "  descending  " 
or  "  ascending "  in  character ;  he  indeed  seems  to  suppose  that,  in 
many  instances  at  all  events,  the  inflammation  commences  at  the  back 
of  the  eyeball  and  ascends  towards  the  cerebrum. 

(3.)  If  it  is  the  fact  that  in  those  cases  of  intracranial  tumour 
in  which  there  is  no  optic  neuritis,  increased  intracranial  pressure  is 
more  frequently  absent  than  in  the  average  run  of  cases — and  my 
own  observation  would  lead  me  to  suppose  that  such  is  the  case — 
this  circumstance  seems  to  me  a  strong  argument  against  the  de- 
scending neuritis  view. 

(4.)  The  fact  that  optic  neuritis,  which  has  once  subsided,  rarely 
relapses  and  returns,  even  although  the  intracranial  tumour  with 
which  it  is  associated  takes  on  renewed  activity,  seems  also  opposed  to 
the  descending  neuritis  theory ;  indeed,  judging  from  analogy,  I  should 
have  supposed  that,  if  the  condition  is  a  true  neuritis,  one  attack 
would  predispose  to,  rather  than  prevent,  the  production  of  a  second. 


THE   CAUSATION  OF  DOUBLE  OPTIC  NEURITIS.      65 

(5.)  The  fact  that  in  unilateral  papillitis  associated  with  tumour, 
the  papillitis  is  usually  ( ?  always)  on  the  opposite  side  to  the  tumour, 
is  also,  to  my  mind,  a  strong  argument  against  the  descending  inflam- 
matory theory. 

(6.)  The  fact  that  tumours  in  the  region  of  the  pituitary  body, 
which  one  would  have  thought  would  be  specially  liable  to  excite 
.inflammatory  changes  in  their  immediate  neighbourhood,  produce, 
in  some  instances  at  all  events,  primary  optic  atrophy,  and  not 
optic  neuritis,  is  also  perhaps  an  argument  against  the  descending 
neuritis  view. 

(7.)  The  fact  that  deafness  very -rarely  results  from  intracranial 
tumour,  while  complete  blindness  from  papillitis  is  common,  is  also, 
I  think,  opposed  to  the  descending  neuritis  theory ;  for  if  the  papil- 
litis is  due  to  a  "  descending  inflammatory  "  process,  why  should  the 
auditory  nerve  not  be  affected  with  "  descending  inflammation  "  too  ? 
It  may  of  course  be  said  that  the  inflammation  does  descend  along 
the  auditory  nerve,  and  that  we  are  unable  to  recognise  it ;  while  we 
are  able  to  see  the  papillitis  by  means  of  the  ophthalmoscope.  The 
argument  is,  however,  fallacious  ;  for,  although  the  minor  degrees  of 
inflammation  of  the  auditory  nerve  might  for  this  reason  pass  unre- 
cognised, the  more  severe  inflammatory  changes  ought  to  produce 
deafness,  just  as  the  more  severe  forms  of  papillitis  do  produce  blind- 
ness. I  see  no  reason  why  severe  inflammatory  changes  in  the  audi- 
tory nerve  terminations,  and  delicate  end-organ  of  hearing,  should  not 
produce  deafness,  just  as  we  know  severe  inflammatory  changes  in  the 
optic  disc  and  end-organ  of  sight  produce  blindness.  And  since 
deafness  does  not,  except  in  the  very  rarest  instances,  result  from 
intracranial  tumours,  I  conclude  that  a  severe  form  of  descending 
neuritis  in  the  auditory  nerve  does  not  occur.  This  constitutes,  in 
my  opinion,  an  argument  against  the  view  that  the  papillitis  is  pro- 
duced by  a  (to  be  strictly  accurate  and  logical)  s&v&rc  inflammatory 
change  descending  along  the  nerve  fibres. 

In  this  connection,  it  is  important  to  remember  the  suggestion 
thrown  out  by  Gowers,  that  "  a  very  slight  degree  of  descending 
inflammation  may  be  the  connection  between  a  neuritis  of  the 
cerebral  and  one  of  the  ocular  extremities  of  the  nerve.  We  know," 
he  says,  "  from  the  occurrence  of  neuritis  in  general  diseases,  that  the 

E 


66  ANAL  YSIS  OF  INDI VI D UAL  S  YMPTOMS. 

optic  papilla  is  a  structure  in  whicli  inflammation  readily  occurs,  and 
it  seems  as  if  a  slight  process  of  irritation  descending  the  nerve  was 
suflficient  to  light  up  a  considerable  papillitis.  We  know  also  that  a 
cerebral  tumour  is  the  seat  of  irritative  changes,  and  it  seems  probable 
that  in  some  cases  such  irritation  may  be  widely  spread,  and  may 
reach  and  descend  the  optic  system  of  fibres."^  Dr.  Buzzard  fully 
realises  the  importance  of  the  argument,  that  if  the  papillitis  is  the 
result  of  a  descending  inflammation,  or  of  vaso-motor  changes  induced 
by  the  irritation  of  cerebral  grey  matter  in  the  neighbourhood  of  the 
tumour,  the  inflammation  ought  not  to  be  limited  to  the  optic,  but 
should  also  involve  the  other  cerebral  nerves.  His  remarks  on  the 
vaso-motor  tlieory  at  the  debate  of  the  Ophthalmological  Society,  were 
as  follows : — "  But  to  make  this  explanation  feasible,  it  appeared  to 
him  that  it  was  necessary  either  to  account  for  the  optic  nerve  being 
singled  out  as  the  solitary  subject  of  the  pathological  change,  or  to 
show  that  it  was  not  singled  out,  but  that  an  analogous  condition  was 
apt  to  prevail  in  the  course  of  the  cranial  nerves.  The  latter  course, 
perhaps,  offered  most  promise.  He  was  disposed  to  think  that  in 
many  cases  the  pains  in  the  head,  associated  with  intracranial  timiour, 
were  due  to  neuritis  of  the  fifth  nerve,  for  although,  perhaps,  they 
were  as  a  rule  not  distinctly  localised,  yet  the  patient  would  some- 
times refer  them  very  clearly  to  the  district  of  that  nerve,  and  tender 
points  would  occasionally  be  found  in  the  situations  similarly  affected 
in  trigeminal  tic.  It  might  be  a  question,  too,  he  thought,  whether  the 
vertigo,  which  w" as  of  not  uncommon  occurrence  in  cases  of  intracranial 
tumour,  might  not  be  due  to  changes  in  the  nerves  supplying  the 
external  ocular  muscles,  producing  waves  of  disordered  function  corre- 
sponding to  those  which  Dr.  Jackson  had  described  as  causing  tem- 
porary loss  of  sight  in  the  case  of  optic  neuritis.  Was  it  possible, 
again,  that  the  vomiting  and  slowing  of  the  pulse  might  represent  an 
affection  of  the  pneumogastric  brought  about  by  the  same  cause  as 
that  which  produced  optic  neuritis,  and  that  the  sudden  or  rapid 
death,  which  Dr.  Jackson  had  mentioned  as  one  of  the  contingencies 
of  optic  neuritis  from  intracranial  disease,  might  also  be  explained  by 
a  more  severe  influence  exerted  upon  the  nerve  ?"- 

^   Transactions  of  the  OphthaJmological  Society  of  the  United  Kingdom,  vol.  i.,  p.  107. 
-  Ibid.,  vol.  i.,  p.  98. 


THE  CAUSATION  OF  DOUBLE  OPTIC  NEURITIS.      67 

These,  then,  are  the  chief  reasons  which  lead  me  to  doubt  whether 
a  descending  inflammatory  process  (more  especially  an  inflammation 
descending  along  the  nerve  fibres)  is  the  usual  cause  of  the  papillitis 
associated  with  intracranial  tumours. 

To  sum  up,  it  appears  to  me  that  the  double  optic  neuritis  asso- 
ciated with  intracranial  tumours  is  not  always  produced  in  the 
same  manner.  It  must  be  allowed  that  in  some  cases  it  is  due 
to  a  "descending"  inflammation,  but  this  does  not  appear  to  me 
to  be  the  usual  or  most  common  cause  of  the  condition.  The 
pressure-irritation  theory  of  Leber  and  Deutschmann  is,  in  my 
opinion,  the  most  likely  explanation  in  the  majority  of  cases.  In- 
creased intracranial  pressure  is  an  important,  though,  as  Deutsch- 
mann suggests,  a  secondary  and  favouring  cause  of  the  condition. 
The  essential  and  primary  cause  is  probably  in  most  cases,  as 
Leber  and  Deutschmann  have  suggested,  the  presence  of  an  irritant 
in  the  cerebro -spinal  fluid.  Increased  intracranial  pressure  is  an 
important  factor,  inasmuch  as  it  forces  the  arachnoid  fluid  into  the 
subvaginal  space,  where  the  irritant  contained  in  the  subarachnoid 
fluid  produces  inflammatory  results  in  the  vaginal  space,  optic  nerve, 
and  optic  papilla.  But  before  the  Leber-Deutschmann  theory  can  be 
definitely  adopted,  the  presence  of  an  irritant,  and  its  exact  nature, 
require,  I  think,  further  demonstration.  The  weight  of  evidence  seems 
to  me  strongly  opposed  to  the  vaso-motor  view. 


CHAPTER    IV. 

MOTOE  DERANGEMENTS— PAEALYSIS— SPASM— TEEMOE— 

CONTEACTUEE. 

Paralysis. 

Derangements  of  motion,  more  especially  paralysis  and  spasm,  are 
of  frequent  occurrence  in  cases  of  intracranial  tumour,  and  are  of 
great  importance  from  a  localising  point  of  view.  The  extent  and 
distribution  of  the  paralysis  is  of  course  very  different  in  different 
cases,  for  a  tumour  may  involve  any  part  of  the  intracranial  neuro- 
motor apparatus : — (a)  cortical  centres ;  (b)  conducting  fibres,  in 
the  centrum  ovale,  internal  capsule,  crus  cerebri,  pons  Varolii,  or 
medulla  oblongata ;  or  (c)  intracranial  portions  of  the  (peripheral) 
cranial  nerves. 

Now,  since  both  at  the  top  and  bottom  of  the  neuro-motor 
apparatus  there  is  anatomical  separation  as  well  as  physiological 
differentiation,  it  follows  that  tumours,  which  involve  the  cortical 
centres  or  peripheral  nerves,  are  much  more  likely  to  produce 
localised  paralyses  than  tumours  which  involve  the  great  bands  of 
conducting  fibres  (see  Fig.  14). 

Cortical  or  subcortical  tumours  of  limited  extent  may  produce 
very  limited  and  localised  paralysis — paralysis  of  one  limb  (mono- 
plegia), or  of  part  of  a  limb — -just  as  excision  of  limited  portions  of  the 
cortex  produces  very  localised  (though  temporary)  paralysis  in  the 
lower  animals.  As  the  tumour  increases  in  size,  adjacent  motor 
centres  may  become  involved,  and  the  lesion  may  gradually  extend, 
until  ultimately  all  the  motor  centres,  or  all  the  conducting  fibres 
proceeding  from  them,  are  involved,  and  the  paralysis  assumes  tlie 
ordinary  hemiplegic  type  {i.e.,  involves  the  face,  arm,  and  leg  on  the 
opposite  side  of  the  body). 

Cortical  or  subcortical  tumours,  wliich  are  situated  in  the  middle 
line  and  which  involve  the  motor  area  in  each  hemisphere,  may 


PARALYSIS. 


69 


Fig.  14. — Diagram  showing  the  arrangement  of  the  motor  tracts  for  both  sides  of 
the  face,  the  left  arm,  and  the  left  leg  ;  and  the  distribution  of  the  paralysis  produced  by 
lesions  in  different  parts  of  the  cerebrum. 

B,  the  right,  and  -B',  the  left  cerebral  hemisphere  ;  P,  the  pons  Varolii ;  M,  the  medulla 
oblongata ;  S,  S,  the  spinal  cord  ;  V  V,  the  lateral  ventricles ;  NC,  the  nucleus  caudatus  ; 
L  N,  the  lenticular  nucleus  ;  C  C,  the  crus  cerebri ;  T'  S',  left  tempore -sphenoidal  lobe  ; 
F,A,L,  cortical  centres  for  the  face,  arm,  and  leg  in  the  right  hemisphere ;  P',  cortical  centre 
for  facial  muscles  in  the  left  cerebral  hemisphere;  1,  1',  right  and  left  facial  nerve  nuclei; 
2,  2',  right  and  left  nerve  nuclei  for  the  upper  extremity  ;  3,  3',  right  and  left  nerve  nuclei 
for  the  lower  extremity  ;  fm  and  fm,  right  and  left  facial  muscles  ;  a'm,  muscles  of  left 
upper,  and  I'm,  muscles  of  left  lower  limb ;  4,  localised  lesion  in  the  cortex,  producing 
paralysis  of  the  opposite  leg ;  5,  lesion  of  the  pyramidal  tract  as  it  enters  the  internal  capsule, 
producing  hemiplegia  on  the  opposite  side  of  the  body  (paralysis  of  the  face,  arm,  and  leg). 


7° 


ANALYSIS  OF  INDIVIDUAL  SYMPTOMS. 


produce  limited  paralysis  on  both  sides  of  the  body.  Paralyses  of  this 
kind  are  certainly  very  rare,  but  it  is  quite  conceivable  that  a  tumour 
of  the  vertex  might  involve  both  leg  centres  and  so  produce  paraplegia. 
Tumours  involving  the  corpus  callosum  may  extend  into  each 
centrum  ovale,  invade  each  internal  capsule,  and  so  produce  paralysis 
(more  or  less  complete  hemiplegia)  on  both  sides  of  the  body. 
Further,  tumours  which  involve  or  press  upon  the  motor  tract  in  the 
pons  Varolii  or  medulla  oblongata,  not  infrecjuently  [produce 
bilaterally  distributed  paralysis,  which  often  involves,  but  seldom 
completely  paralyses,  all  four  extremities. 


fm 


Fig.  15. — Diagram  sho-i^-ing  the  arrangement  of  the  motor  tracts  for 
both  sides  of  the  face,  the  left  arm,  and  the  left  leg  in  the  pons  Varolii,  and 
the  distribution  of  the  paralysis  produced  by  lesions  of  different  parts  of  it. 

6,  lesion  in  the  upper  part  of  the  right  side  of  the  pons,  producing  paralysis 
of  the  face,  arm,  and  leg  on  the  opposite  (left)  side  ;  7,  lesion  in  the  lower 
part  of  the  right  side  of  the  pons  Varolii,  producmg  paralysis  of  the  face  on 
the  same,  and  of  the  arm  and  leg  on  the  opposite  side ;  8,  lesion  in  the  middle 
of  the  left  side  of  the  pons  Varolii,  producing  paralysis  of  both  sides  of  the 
face,  and  of  the  arm  and  leg  on  the  opposite  side, — the  conducting  tracts 
passing  to  the  right  arm  and  leg  are  not  shown  in  the  left  side  of  the  pons, 
but  they  would  obviously  be  interrupted  by  this  lesion. 

It  must  be  remembered  that  in  many  cases  of  cerebral  tumour  there 
is  more  than  one  focus  of  new  growths  ;  and  that  it  is  quite  possible 
to  have  irregular  forms  of  paralysis  where  there  are  multiple  lesions. 

Tumours  which  involve  one  pyramidal  tract,  either  in  the  internal 
capside,  crus  cerebri,  pons  Varolii,  or  medulla  oblongata,  usually 
cause  hemiplegia,  for  they  usually  involve,  more  or  less  completely, 
all  the  bundles  of  fibres  of  which  the  pyramidal  tract  is  composed. 


PARALYSIS.  71 

When  the  lesion  is  above  the  cms  cerebri,  the  hemiplegia  is  of  the 
ordinary  type.  When  the  lesion  involves  the  crus  cerebri,  or  is 
situated  in  the  pons  Varolii  or  mednlla  oblongata,  one  or  other  of  the 
irregular  or  alternate  forms  of  hemiplegia  may  result,  viz.  : — (1.) 
Paralysis  of  the  face,  arm,  and  leg  on  the  opposite  side  to  the  lesion, 
and  of  the  muscles  supplied  by  the  third  nerve  on  the  same  side ;  (2.) 
Paralysis  of  the  arm  and  leg  on  the  opposite,  and  of  the  face  on  the 
same  side  as  the  lesion  (see  Fig.  15) ;  (3.)  Paralysis  of  the  arm  and 
leg  on  the  opposite,  and  of  the  muscles  supplied  by  the  facial  (seventh) 
and  sixth  nerve  (external  rectus)  on  the  same  side  ;  (4.)  Paralysis  of 
the  arm  and  leg  on  the  opposite,  and  of  the  face  on  both  sides  (see 
Fig.  15) ;  (5.)  Paralysis  of  the  face,  arm,  and  leg  on  the  opposite  side, 
and  anaesthesia  (from  paralysis  of  the  fifth  nerve)  on  the  same  side  of 
the  face ;  (6.)  Paralysis  of  the  arm  and  leg  on  the  opposite,  and  of 
the  tongue  on  the  same  side. 

Tumours  at  the  base  of  the  brain  may  involve  one  or  more  of  the 
peripheral  nerves  (third,  fourth,  sixth,  seventh,  &c.)  on  one  or  both 
sides,  and  produce  a  localised  peripheral  paralysis,  or  different  combi- 
nations of  peripheral  paralysis.  In  cases  of  this  kind  the  distribution 
of  the  paralysis  is  different  from  that  due  to  a  localised  cortical  lesion, 
and  the  condition  of  the  paralysed  muscles  is  usually  characteristic. 

Further,  in  addition  to  involving  one  or  more  of  the  peripheral 
nerves,  a  tumour  at  the  base  may  obstruct  the  middle  cerebral  artery, 
or  some  of  its  branches,  and  may  consequently  produce  softening  in 
the  motor  area  of  the  cortex  (on  the  same),  and  therefore  hemiplegia 
on  the  opposite  side  of  the  body.  The  form  of  alternate  hemiplegia 
in  which  the  face,  arm,  and  leg  are  paralysed  on  the  opposite,  and  the 
muscles  supplied  by  the  third  nerve  on  the  same  side  as  the  lesion, 
and  which,  when  sudden  and  acute,  is  distinctive  of  a  lesion  of  the 
crus  cerebri,  may  therefore  be  produced  by  a  tumour,  usually  a 
syphilitic  gumma,  at  the  base  of  the  brain  involving  the  trunk  of  the 
third  nerve  and  the  trunk  of  the  middle  cerebral  artery. 

The  condition  of  the  paralysed  muscles  (their  state  of  nutrition, 
and  their  electrical  reactions),  the  condition  of  the  reflexes,  and  the 
presence  of  twitchings,  tremors,  and  spasms,  depend  upon  the  position 
and  character  of  the  lesion.  Whether  the  resulting  paralysis  is  central 
or  peripheral — or,  more  correctly,  whether  it  is  due  to  a  lesion  (1) 


72  ANALYSIS  OF  INDIVIDUAL  SYMPTOMS. 

cibove  or  (2)  in  or  helow  the  nerve  nuclei  of  the  affected  muscles — is 
of  course  the  most  important  point. 

It  is  important  to  note,  that  in  the  various  forms  of  alternate 
hemiplegia  the  muscles  which  are  paralysed  on  the  same  side  as  the 
lesion  present  the  atrophy,  electrical  reactions,  and  reflex  alterations 
which  are  characteristic  of  peripheral  paralysis,  whereas  those  on  the 
opposite  side  present  all  the  characteristics  of  a  paralysis  due  to  a 
central  (cerehral)  lesion  (i.e.,  a  lesion  above  the  nerve  nucleus). 

Localised  convulsive  twitchings,  or  attacks  of  "  Jacksonian "  epi- 
lepsy, often  precede  or  are  associated  with  the  paralyses  which  are  due 
to  cortical  or  subcortical  lesions ;  for  the  process  of  irritation  often 
precedes,  or  is  associated  with,  the  process  of  destruction  which  is 
produced  by  a  tumour. 

A  rhythmical  tremor,  occurring  on  attempts  at  voluntary  move- 
ment, which  closely  resembles  the  tremor  of  cerebro-spiual  sclerosis, 
and  which  is  due  to  pressure  upon,  and  interrupted  conduction  through, 
the  fibres  of  the  pyramidal  tract,  is  met  with  in  some  cases.  It  is 
not  infrequently  due  to  the  pressure  of  a  cerebellar  tumour  upon  the 
pons  Varolii  or  medulla  oblongata ;  and  I  have  met  with  cases  in 
which  it  had  apparently  resulted  from  the  pressure  of  new  growths  in 
the  region  of  the  centrum  ovale,  upon  the  motor  fibres  of  the 
internal  capsule.^ 

In  this  connection  I  may  say  that  I  am  doubtful  if  simjjle  pressure 
on  the  fibres  of  the  pyramidal  tract  (i.e.,  pressure  without  irritation) 
produces  exaggeration  of  the  knee  jerk,  as  is  generally  supposed. ^ 

It  will  be  apparent  from  what  has  just  been  stated,  that  the  extent 
and  distribution  of  the  x^aralysis,  and  the  condicion  of  the  paralysed 
muscles,  reflexes,  &c.,  afford  in  many  cases  most  important  informa- 
tion as  to  the  exact  position  of  the  tumour. 

In  all  cases  of  intracranial  tumour  in  which  spasm  cr  paralysis 
appears  to  be  due  to  a  cortical  lesion,  it  is  advisable  to  refer  to  the  experi- 
mental results  obtained  by  Terrier  and  others  in  the  lower  animals. 
It  is  perhaps  premature  to  conclude  that  the  results  of  cortical  irrita- 
tion in  the  monkey  exactly  correspond  with  those  in  man  ;  but  the 

^   See  a  case  which  I  have  reported  in  the  Edhiburgh  Medical  Joitrnal  for  January 
1887,  p.  623. 
-  Ibid. 


PARAL  YSIS. 


73 


effects  of  disease  in  the  human  subject  seem  to  show  that  the  plan  of 
arrangement  in  the  two  brains  is,  as  regards  the  motor  centres  at  all 
events,  very  similar. 

In  Figs.  16  and  17  the  position  of  the  motor  centres,  as  deter- 
mined by  Terrier  on  the  lateral  and  upper  aspects,  and  in  Fig.  18  by 


Fig,  16. — Lateral  view  of  the  human  brain,  showing  the  position  of  the 
motor  centres.     (After  Terrier. ) 

1 .  Centre  for  opposite  leg  and  foot. 

2,  3,  4.   Centres  for  movements  of  arms  and  legs,  such  as  are  concerned  in 

climbing,  swimming,  &c. 

5.  Centre  for  extension  forwards  of  the  arm  and  hand. 

6.  Centre  for  the  supination  of  the  hand  and  flexion  of  the  fore-arm. 

7.  8.  Centres  for  elevators  and  depressors  of  mouth  respectively. 

9,  10.  Centre  for  the  movements  of  the  lips  and  tongue  in  articulation. 

11.  Centre  for  the  platysma  ;  retraction  of  the  angle  of  the  mouth. 

12.  Centre  for  lateral  movements  of  the  head  and  eyes,  with  elevation  of 

the  eyelids  and  dilatation  of  the  pupil. 
a,  h,  c,  d.  Centre  for  the  movements  of  the  hand  and  wrist. 

Centre  5  involves  the  posterior  end  of  the  first ;  12,  the  posterior  end  of 
the  second  ;  and  9,  the  posterior  end  of  the  third  frontal  convolutions. 

Centres  2,  3,  4,  6,  7,  8,  and  9  are  placed  on  the  ascending  frontal  convo- 
lution. 

Centre  1  involves  the  posterior  parietal  lobule,  and  centres  11,  a,  b,  e, 
and  d,  are  placed  on  the  ascending  parietal  convolution. 

Centres  13  and  13'  (Ferrier's  centres  for  vision)  are  placed  on  the  supra- 
marginal  convolution,  angular  gyrus,  and  occipital  lobe. 

Centres  14,  14  (Ferrier's  centres  for  hearing)  on  the  superior  temporo- 
sphenoidal  convolution. 


74 


ANAL  YSIS  OF  INDI VI D  UAL  S  YMF  TO  MS. 


Victor  Horsley  and  Schafer  on  the  inner  aspect  of  the  brain  of  the 
monkey,  is  shown. 

Stated  in  detail,  the  results  obtained  by  Horsley  and  Schafer 
were  as  follows  : — 

"  The  general  results  of  our  experiments,"  they  say,  "  will  best  be 
understood  by  a  reference  to  the  accompanying  figure  (Fig.  18).  Thus, 
in  the  part  of  the  marginal  convolution  marked  1,  1',  extending  from 


Fig.  17. — Upper  view  of  the  human  brain,  showing  the  position  of  the 
motor  centres.     (After  Terrier.) 

just  in  front  of  the  small  vertical  sulcus  3/  to  a  point  on  a  level  with 
the  anterior  third  of  the  small  antero-posterior  sulcus  x,  excitation  is 
followed  by  either  movements  of  the  fore-arm  (flexion  or  extension),  or 
by  adduction  of  the  arm  and  retraction  of  the  shoulder  combined 
with  outward  rotation,  or  by  any  of  these  movements  of  shoulder  and 
arm  either  combined  or  succeeding  one  another  in  definite  order, 
according  to  the  point  in  the  area  which  is  stimulated.     Eetraction 


PARAL  YSIS. 


75 


of  the  shoulder  (combined  with  flexion  of  the  fore-arm)  is  alone  pro- 
duced by  excitation  of  the  posterior  portion  of  this  area,  and  when 
manifested  as  the  result  of  excitation  applied  here,  is  apt  to  be  asso- 
ciated with  movements  of  the  trunk,  pelvis,  or  hip,  which,  as  the 
overlapping  of  the  contours  of  the  areas  shows,  may  also  be  called 
forth  by  excitation  of  this  part. 

"  In  the  next  area,  2,  2',  we  get  movements  of  the  trunk  muscles 
as  the  result  of  excitation,  the  chief  effect  produced  being  a  rotation  of 


Fig.  18. — Inner  aspect  of  the  right  hemisphere  of  the  brain  of  a  monkey, 
showing  the   position   of    the   motor   areas   in   the   marginal  convolution, 
according  to  Horsley  and  Schafer. 
The  centres  overlap  one  another. 

From  1  to  1'  =  centre  for  the  upper  extremity. 
2  to  2'  =  centre  for  the  trunk  muscles. 
4  to  4'  ==  centre  for  the  lovi^er  extremity. 
The  movements  from  before  backwards  seem  to  be  arranged  in  the  fol- 
lowing order  : — (1.)  movements  of  the  head  ;  (2.)  of  the  fore-arm  and  hand  ; 
(3.)  of  the  arm  at  the  shoulder ;  (4.)  of  the  upper  (dorsal)  part  of  the  trunk  ; 
(5.)  of  the  lower  (pelvic)  part  of  the  trunk  ;  (6.)  of  the  leg  at  the  hip  ;  (7.) 
of  the  lower  leg  at  the  knee  ;  (8.)  of  the  foot  and  toes. 

the  body  to  the  opposite  side  to  that  stimulated,  combined  with  an 
arching  of  the  spine,  with  the  concavity  directed  towards  the  opposite 


76  ANALYSIS  OF  INDIVIDUAL  SYMPTOMS. 

side.  In  the  anterior  part  of  the  area  the  chief  effect  is  upon  the 
dorsal  region,  but  in  the  posterior  part  it  is  upon  the  lumbar  region 
and  pelvis. 

"  This  area  is  largely  overlapped  by  the  next  one,  3,  ?>' ,  excita- 
tion within  which  is  followed  by  movements  of  the  hip,  at  some  points 
the  flexors  only,  at  others  the  extensors  only,  at  others  both  sets  of 
muscles  being  called  into  contraction  simultaneously.  As  will  appear 
from  the  overlapping  of  the  areas  in  the  figure,  these  movements  of 
the  hip  are  apt  to  be  associated  with  the  rotatory  and  bending  move- 
ments of  the  trunk  above  mentioned ;  but  in  the  anterior  part  of  the 
area  it  is  generally  the  rotation  of  the  trunk  and  pelvis  which  is  first 
seen,  and  this  is  followed  by  hip  movements,  whereas  in  the  centre  of 
the  area,  movements  of  the  hip  may  be  the  first  to  appear,  or  with  a 
very  weak  excitation  may  be  the  only  ones  visible. 

"  The  next  area,  4,  4',  is  very  extensive.  It  considerably  over- 
laps the  areas  2,  2',  and  3,  3',  and  extends  to  the  posterior  limit 
of  the  convolution.  Its  excitation  calls  up  contractions  of  the  thigh 
muscles,  and  especially  of  the  hamstrings,  which  in  some  parts  are  the 
only  muscles  affected  by  weak  stimulation — indeed,  in  some  instances 
the  contractions  of  the  individual  hamstring  muscles  were  perfectly 
localised.  But  in  most  parts  of  the  area,  as  the  overlapping  of  the 
contours  show,  these  movements  are  associated  with  those  of  other 
muscles,  viz.,  anteriorly  with  the  trunk  and  hip  muscles,  and  pos- 
teriorly with  muscles  which  move  the  ankle  and  toes.  These  asso- 
ciated movements  may  be  simultaneous,  but  are  most  commonly 
successive,  as  when  by  stimulation  of  one  point  there  was  produced, 
first,  a  contraction  of  one  of  the  abdominal  muscles,  then  of  one  of 
the  thidi  muscles,  and  then  of  one  of  the  muscles  which  move 
the  ankle. 

"  In  like  manner  the  area  marked  5,  5',  may  be  looked  upon  as 
the  specialised  part  from  which  the  movements  of  the  ankle  are  con- 
trolled, these  being  usually  the  first  to  appear  on  exciting  the  area, 
although  very  generally  associated  with  or  followed  by  movements  of 
the  hip  and  knee.  And  6,  6',  may  for  a  similar  reason  be  looked 
upon  as  specially  controlling  certain  movements  of  the  toes,  generally 
associated,  however,  with  other  movements  of  the  lower  limb.  As 
before  mentioned  with  regard  to  the  other  areas,  the  particular  move- 


PARALYSIS.  77 

ments  called  forth  differ  according  to  the  point  in  the  area  which  is 
excited,  but  our  experiments  do  not  as  yet  enable  us  to  make 
sufficiently  positive  assertions  as  to  the  localisation  of  these 
specialised  points."  ^ 

See  also,  with  reference  to  the  more  exact  position  of  the 
motor  centres,  Victor  Horsley's  paper  on  the  "Topography  of  the 
Cerebral  Cortex,"  in  the  International  Medical  Journal  for  April 
1887,  page  342 ;  and  Horsley  and  Schafer,  "  A  Eecord  of  Experi- 
ments upon  the  Functions  of  the  Cerebral  Cortex," — Philosophical 
Transactions,  vol.  179  (1888),  B.,  pp.  1-45. 

The  causes  of  paralysis  in  cases  of  cerebral  tumour  are  numerous. — 
(1.)  In  some  cases  the  paralysis  is  due  to  destruction  of  some  part  of 
the  intracranial  neuro-motor  apparatus  (centres,  conductors,  peripheral 
cranial  nerves) ;  and,  as  has  been  previously  stated,  this  destruction 
may  either  be  the  direct  result  of  the  lesion,  or  due  to  obstruction  of 
the  blood  supply — i.e.,  indirect. 

It  must  be  remembered  that  slow  and  gradual  destruction  of  a  large 
portion  of  the  motor  cortex  {i.e.,  motor  grey  matter)  is  not  necessarily 
attended  with  paralysis  (see  Figs.  1,  2,  3,  and  4,  pp.  11-14) ;  but  that 
in  those  cases  of  cerebral  tumour  in  which  the  paralysis  is  due  to  this 
cause,  the  loss  of  motor  power  is  usually  permanent. 

(2.)  In  others,  the  paralysis  is  due  to  the  pressure  of  the  tumour, 
or  of  the  inflammatory  products  which  surround  it,  upon  conducting 
(motor)  fibres.  In  cases  of  this  kind,  the  extent  and  degree  of  the 
paralysis  may  vary  from  time  to  time  in  consequence  of  variations  in 
the  degree  and  severity  of  the  pressure.^ 

(3.)  In  other  cases  the  paralysis  is  temporary,  and  due  to  passing 
(?  functional)  changes  in  the  motor  centres.  Post-epileptic  paralysis, 
which  follows  the  spasms  of  "  Jacksonian "  epilepsy  (and  which  is 
probably  due  to  exhaustion  of  the  grey  matter  which  was  violently 
discharged  during  the  attack),  is  the  best  known  form  of  functional 
cerebral  paralysis. 

Another  variety,  which  is  neither  preceded  by  spasm  nor  uncon- 
sciousness, and  in  which  there  is  sudden  but  temporary  failure  of  motor 
power,  is  much  more  rare.     I  have,  however,  met  with  several  well- 

^  Proceedings  of  the  Royal  Society  of  London,  vol.  xxxvi.,  p.  439. 

^  See  a  case  reported  by  me  in  the  Edinhurfjii  Medical  Journal  for  .Jan.  1887,  p.  623. 


78  A IV A  LYSIS  OF  INDIVIDUAL  SYMPTOMS. 

marked  instances,  and  am  disposed  to  think  that  it  is  due  either  to 
temporary  alterations  (arrest)  in  the  lolood  supply,  or  to  inhibition 
of  motor  grey  matter.  ^ 


Spasms  and  Convulsions. 

The  increased  and  perverted  function,  which  is  so  frequently  pro- 
duced in  motor  nerve  tissue  by  intracranial  tumours,  is  manifested 
externally  in  the  form  of  spasms  and  convulsions,  and  the  lesion  is 
technically  termed  a  "discharging"  one.  It  is  obvious,  as  Dr.  Hughlings 
Jackson,  who  introduced  the  terms  "  discharging  "  and  '•'  destroying," 
has  pointed  out,  that  it  is  not  the  tumour  itself  which  discharges, 
but  the  motor  nerve  tissue  which  is  irritated  by  it. 

Theoretically  a  tumour  or  other  "  coarse  "  lesion  may  cause  dis- 
charge of  motor  grey  matter,  either  by  directly  irritating  it ;  or 
indirectly  (1)  by  interfering  with  the  nutrient  supply  (pressing  upon 
and  obstructing  the  blood  -  flow  through  its  nutrient  vessels,  or 
irritating  their  vaso-motor  nerves) ;  or  (2)  by  reflexly  irritating  it,  the 
irritation  passing,  perhaps,  in  some  instances,  in  the  first  place  to  the 
convulsive  centre  in  the  medulla. 

Further,  Duret  has  shown  that  spasms  and  convulsions  may  be 
produced  by  irritating  sensory  nerves  in  the  dura  mater;  but  the 
spasms  which  are  produced  in  this  way  have  not  the  well-defined 
and  characteristic  features  of  the  localised  epileptiform  convulsions, 
due  to  irritation  of  the  motor  cortical  centres,  which  will  pre- 
sently be  described. 

The  character  of  the  convulsions,  whether  tonic  or  clonic,  depends, 
in  part  at  least,  upon  the  composition  of  the  nerve  tissue  which  is 
irritated  (whether  grey  or  white  matter). 

Clonic  s^pasms  and  epileptiform  convulsions,  which  are  by  far  the 
most  important  forms  of  spasms  met  with  in  cases  of  intracranial 
tumour,  may  theoretically  result  from  irritation  of  motor  grey  matter 
either  in  the  cerebrum  itself,  in  the  pons  Varolii,  or  medulla  oblongata ; 
but  are,  I  think,  in  the  great  majority  of  cases  due  to  discharge  of 
motor  grey  matter  (motor  centres)  in  the  cerebral  cortex. 

^  See  a  case  which  I  have  reported  in  the  Edinburgh  Medical  Journal  for  Dec.  1878, 
p.  501,  in  which  the  form  of  paralysis  was  a  striking  symptom. 


LOCALISED  EPILEPTIFORM  CONVULSIONS.  79 

The  extent  and  distribution  of  the  spasms  are  very  variable.  In 
some  cases  a  single  muscle  or  group  of  muscles  is  involved  ;  in.  others 
the  muscles  of  one  limb  are  affected ;  in  others,  again,  the  spasm  is 
unilateral,  while  in  some  the  spasm  is  bilateral,  and  affects  all,  or 
almost  all,  the  muscles  of  the  body. 

In  localised  epileptiform  convulsions,  or  attacks  of  Jacksonian 
epilepsy,  as  they  are  commonly  termed,  there  is  usually  no  loss  of 
consciousness ;  but  in  those  cases  in  which  the  spasm  is  from  the  first, 
or  in  which  it  subsequently  becomes,  general  and  bilateral,  conscious- 
ness is  usually,  but  not  invariably,  lost,  and  the  patient  foams  at  the 
mouth ;  in  short,  the  attack  exactly  resembles  an  ordinary  (idiopathic) 
epileptic  fit.  In  the  Eclinhurgh  Medical  Journal  for  January  1879, 
p.  599, 1  have  described  a  case  of  this  kind,  in  which  there  was  no 
loss  of  consciousness,  although  the  spasms  were  bilateral  and  very 
severe.     This  is  extremely  rare. 

Another  characteristic  feature  of  the  localised  convulsions  of  Jack- 
sonian epilepsy  is  the  fact  that  they  are  usually  followed  by  tem- 
porary localised  paralysis,  affecting  those  muscles  which  were  first 
or  most  convulsed.  Dr.  Hughlings  Jackson  thinks  that  after  the 
bilateral  spasms  of  ordinary  epilepsy  there  is  also  some  paralysis,  but 
that  it  is  less  perceptible,  being  universally  or  thinly  spread  out  over 
the  whole  muscular  system. 

Now  it  is  important  to  remember  that  the  discharge,  which  results 
from  the  irritation  which  a  tumour  or  other  "  coarse  "  lesion  produces 
in  a  limited  portion  of  the  motor  area  of  the  cerebral  cortex,  has  the 
same  strong  tendency  to  extend  to,  and  to  involve,  adjacent  and  more 
distant  centres,  and  so  eventually  to  produce  general  and  bilateral 
convulsions,  as  the  discharge  induced  by  electrical  irritation  of  a 
localised  portion  of  the  motor  cortex  in  the  lower  animals.  In  both 
cases  the  spread  or  march  of  the  spasm  is  not  haphazard,  but  follows 
a  definite  course.  The  following  case  is  a  striking  illustration  of  many 
of  the  points  which  have  just  been  mentioned. 

M.  C,  aged  thirty-seven,  was  admitted  to  the  Newcastle-on-Tyne 
Infirmary  under  my  care  on  May  the  23d,  1875,  suffering  from  right- 
sided  convulsions  and  hemiplegia. 

Seven  years  previously  she  had  received  a  severe  blow  on  the  left 
side  of  the  head,  which  had  fractured  her  skull.     After  the  immediate 


8o  AJVA  L  YSIS  OF  INDIVID  UAL  S  YMPTOMS. 

effects  of  this  injury  were  recovered  from,  she  had  enjoyed  good 
health,  complaining  occasionally  of  a  feeling  of  "  pins  and  needles  " 
in  the  right  forefinger  and  thumb.  The  present  attack  commenced 
on  May  10th,  after  a  heavy  drinking  bout. 

On  examination,  a  depression,  the  size  of  a  threepenny  piece,  could 
be  felt  two  inches  above  the  left  ear;  the  right  arm  and  leg  were 
completely  paralysed ;  and  every  few  minutes  the  patient  was  seized 
with  a  convulsion. 

The  fits  were  of  three  kinds,  and  may,  for  convenience  of  descrip- 
tion, be  termed  slight,  moderate,  and  general. 

In  the  first  or  slight  form  the  muscles  of  the  face  and  neck  were 
alone  affected.  Both  eyes  were  firmly  closed,  and  the  right  corner  of 
the  mouth  drawn  down  in  tonic  spasm,  the  platysma  being  rigid.  The 
eyes  were  then  partly  opened ;  the  head  and  eyeballs  slowly  rotated 
to  the  right.  Clonic  spasms  next  occurred  in  both  eyelids,  the  right 
being  affected  much  more  powerfully  than  the  left ;  and  in  the  muscles 
of  the  tongue  and  right  side  of  the  face  and  neck,  the  platysma  being 
chiefly  affected.  After  a  short  interval,  the  spasms  became  less 
frequent,  the  head  and  eyeballs  were  slowly  turned  back  to  the 
middle  line,  the  eyelids  were  widely  dilated,  and  the  patient  pre- 
sented an  animated  appearance.  The  eyeballs  were  finally  rotated 
upwards  and  to  the  left,  the  eyelids  closed,  and  the  patient  apparently 
fell  asleep. 

In  the  second  or  moderate  form,  the  convulsions  commenced  as 
before.  After  the  head  had  been  rotated  to  the  right,  and  as  the 
clonic  spasms  were  commencing,  the  fingers  of  the  right  hand  were 
drawn  in  to  the  palm,  the  hand  was  then  flexed  at  the  wrist,  and  the 
forearm  bent  to  a  right  angle  and  placed  across  the  chest.  The 
muscles  of  the  right  leg  at  the  same  time  became  rigid,  and  the  foot 
strongly  inverted.  Clonic  spasms  then  occurred  in  the  muscles  of 
the  arm  and  fore-arm,  the  flexors  being  chiefly  affected.  A  few  spas- 
modic twitchings  were  to  be  seen  in  the  leg  and  thigh,  chiefly  in  the 
extensors.     There  was  never  any  flexion  of  the  hip  or  knee. 

In  the  third  variety,  the  convulsions  became  general.  The  fit 
commenced  as  before,  and  passed  through  the  various  stages 
enumerated  above.  After  flexion  of  the  right  fore-arm,  the  arm  was 
slowly  raised  at  the  shoulder  until  it  was  nearly  at  a  right  angle  with 


LOCALISED  EPILEPTIFORM  CONVULSIONS.  8i 

the  body ;  the  tonic  spasm  then  passed  to  the  muscles  of  the  left  arm 
and  of  the  left  leg  in  the  following  order  : — the  fingers  of  the  left  hand 
were  first  drawn  in  to  the  palm ;  the  arm  was  then  raised  upwards 
and  brought  over  to  the  right  side,  so  that  the  hand  approached  the 
forehead ;  the  left  leg  was  at  the  same  time  flexed  upon  the  abdomen, 
the  knee  being  slightly  bent,  the  toes  spread  out,  and  the  foot  flexed 
at  the  ankle  joint.  The  tonic  spasm  soon  passed  off,  and  a  general 
clonic  spasm  of  the  muscles  then  occurred,  the  patient  foaming  at  the 
mouth  and  making  a  cackling  noise.  As  the  clonic  spasms  occurred, 
the  left  arm  was  abducted  and  placed  at  a  right  angle  with  the  body, 
the  under  surface  of  the  arm,  fore-arm,  and  hand  being  uppermost. 
When  the  spasm  passed  to  the  left  arm  and  left  leg,  both  sides  of  the 
face  were  strongly  convulsed. 

In  the  general  convulsions,  the  muscles  of  the  right  side  of  the 
body  were  more  powerfully  contracted  than  those  of  the  left,  and  the 
body  tended  to  turn  over  towards  the  right  side. 

The  slight  fits  occurred  every  few  minutes ;  the  intermediate  form 
frequently  ;  the  general  convulsions  only  occasionally.  Tim  sequence 
of  the  spasm  never  varied  from  that  described. 

On  May  30th  the  patient  died.  On  post-mortem  examination  a  sharp, 
lancet-shaped  spiculum  of  bone,  about  a  quarter  of  an  inch  in  length,  was 
found  projecting  inwards  from  the  margin  of  a  small  oval  aperture  on 
the  left  parietal  bone.  The  exostosis  had  produced  a  very  limited  lesion 
of  the  cerebral  cortex  (see  Fig.  19)  at  a  point  which  very  closely  corre- 
sponds to  Terrier's  centre  for  the  platysma. — (See  11,  Eig.  16,  page  73.)  ^ 

The  limited  epileptiform  spasms  characteristic  of  Jacksonian 
epilepsy  are  of  the  greatest  diagnostic  (localising)  value,  for,  with 
perhaps  some  exceptions,  they  show  that  there  is  a  "  discharging  " 
lesion  in  the  motor  area  of  the  cerebral  cortex  ;  and  further,  in  many 
cases  they  indicate  the  exact  position  of  the  lesion.^ 

In  order  to  determine  the  latter  point  (the  exact  position  of  the 
lesion),  it  is  necessary  to  observe  the  exact  mode  of  commencement  of 
the  spasm.  Our  knowledge  of  the  functions  of  the  different  portions 
of  the  motor  cortex,  and  of  the  relationship  of  these  areas  or  centres 

^  The  case  is  reported  in  the  British  Medical  Journal,  vol.  ii.,  1877,  p.  290,  and  in 
the  Edinburgh  Medical  Journal  for  August  1878. 

'^  See  with  reference  to  this  point  the  remarks  on  p.  85. 

F 


8 2  ANAL  YSIS  OF  INDIVID  UAL  S  YMPTOMS. 

to  the  exterior  of  the  skull,  is  now  so  far  advanced  that  if  we  know 
the  muscle  or  muscles  which  are  first  convulsed,  we  can,  in  many- 
cases,  indicate  with  great  exactitude,  not  only  the  particular  centre  or 
mass  of  grey  matter  which  is  discharged,  but  also  the  point  on  the 
surface  of  the  skull  which  is  superficial  to  it. 

Further,  Victor  Horsley  has  shown  that  localised  spasms  may  be 
elicited  by  electrical  irritation  of  portions  of  the  human  motor  cortex ; 
and  that  by  observing  the  exact  character  of  these  spasms  it  is 
possible  to  identify  the  portion  of  cortex  which  is  exposed  and  irritated. 


Fig.  19. — Outline  of  the  left  hemisphere  of  the  brain  in  the  case  of 
Mary  0. 

The  letter  F  points  to  the  frontal,  and  0  to  the  occipital  end  of  the 
brain  ;  S,  S'  to  the  fissure  of  Sylvius  ;  R,  R'  to  the  fissure  of  Rolando  ;  A  F 
and  A  P  to  the  ascending  frontal  and  parietal  convolutions.  The  white 
circle  represents  the  position  of  the  lesion. 

Now,  in  the  great  majority  of  cases,  in  which  localised  epilepti- 
form convulsions  are  due  to  a  lesion  in  the  motor  area  of  the  cerebral 
cortex,  the  lesion  is  what  we  term  a  "  coarse  "  or  naked-eye  lesion  ; 
and  one  of  the  most  common  forms  of  localised  "  coarse  "  discharging 
lesion  is  a  tumour.  Localised  convulsions  may,  however,  be  due  to  a 
localised  and  limited  softening,  or  a  localised  meningitis. 

We  may  therefore  say  that,  when,  in  addition  to  the  general 
symptoms  of  tumour  (headache,  vomiting,  double  optic  neuritis,  &c.), 
there  are  localised  epileptiform  convulsions,  the  diagnosis  of  the 
tumour  is  strengthened  and  confirmed ;  and  further,  that  the  position 
of  the  tumour  is  in  many  cases  more  or  less  accurately  indicated. 


LOCALISED  EPILEPTIFORM  CONVULSIONS.  83 

But  even  in  those  cases  in  which  the  general  symptoms  of  tumour 
are  absent,  the  presence  of  localised  epileptiform  convalsions  is 
suggestive  of  a  tumour ;  for  the  absence  of  general  symptoms  (head- 
ache, vomiting,  double  optic  neuritis)  does  not  necessarily  exclude 
tumour.  The  point  is  one  of  practical  importance,  for  I  agree  with 
Dr.  Hughlings  Jackson  in  thinking  that  the  frequent  recurrence  of 
localised  epileptiform  convulsions  (more  especially  when  they  tend  to 
become  general,  and  when  the  general  condition  of  the  patient 
demands  it)  calls  for  operative  procedure  and  excision  of  the  discharg- 
ing mass  of  grey  matter. 

Further,  localised  epileptiform  convulsions  are  of  some  value  in 
enabling  us  to  form  a  pathological  diagnosis ;  for  undoubtedly  the 
"  coarse  "  lesions,  which  most  frequently  involve  the  motor  cortex  and 
act  as  discharging  lesions,  are  syphilitic  and  tubercular  deposits. 

General  epileptiform  convulsions,  in  which  the  spasm  simul- 
taneously involves  a  large  number  of  muscles  on  both  sides  of  the 
body,  and  in  which  the  patient  becomes  unconscious,  may  result 
from  a  tumour  in  any  part  of  the  intracranial  cavity,  but  are  more 
rare  than  the  localised  spasms  just  described.  General  epileptiform 
convulsions  of  this  kind  {i.e.,  in  which  the  spasm  is  bilateral  from  its 
onset)  must  be  clearly  distinguished  from  the  generalised  epilepti- 
form convulsions  which  so  frequently  result  from  the  extension  of  the 
discharge  in  cases  of  Jacksonian  epilepsy.  They  are  probably  due 
either  to  vascular  changes,  or  to  reflex  irritation  excited  by  the  tumour  or 
by  the  inflammatory  changes  in  its  neighbourhood  ;  in  some  cases  the 
reflex  irritation  may  perhaps  pass  to  the  so-called  "  convulsive  centre  " 
in  the  medulla  ;  in  others,  directly  to  the  motor  regions  of  the  cortex. 

In  other  cases — but  these  constitute  a  small  minority — the  general 
convulsions  are  the  result  of  hsemorrhagic  extravasations  in  or 
about  the  tumour. 

In  some  cases  the  patient  dies  during  the  attack — a  remarkable 
difference  between  the  general  convulsions  associated  with  tumour 
and  the  general  convulsions  of  idiopathic  or  genuine  epilepsy,  for  in 
the  latter  condition  a  single  fit  is  rarely  fatal. 

General  epileptiform  convulsions  are  of  no  localising  value,  unless 
they  have  a  distinct  local  commencement,  or  unless  they  are  pre- 
ceded by  a  well-defined  and  localised  aura,  indicative  of  the  motor  or 


84  ANALYSIS  OF  INDIVIDUAL  SYMPTOMS. 

sensory  area  of  the  cortex  which  is  first  discharged,  from  which  the 
discharge  spreads,  and  in  the  immediate  neighbourhood  of  which  the 
lesion  is  in  many  instances  situated.  The  character  of  the  aura,  and 
the  mode  of  commencement  of  the  spasms,  may  indicate  the  position 
of  the  lesion,  and  should  therefore  in  all  cases  be  carefully  investigated. 

The  com2oarative  value  of  limited  paralysis  and  limited  epileptiform 
convulsions  as  localising  symp)toms  has  given  rise  to  some  discussion. 
The  generally  accepted  opinion  is  that  the  former  (paralysis)  is  the 
more  important ;  for  the  motor  discharge,  which  produces  spasm, 
may  be  due  to  irritation  arising  at  a  distance  from  the  portion  of 
grey  matter  which  is  discharged ;  and  the  position  of  tlie  centre 
which  is  discharged  is  therefore  an  uncertain  indication  of  the 
position  of  the  lesion. 

With  this  opinion,  I,  for  the  most  part,  agree.  Certain  quali- 
fications are,  however,  I  think,  necessary.  The  discharge  which 
produces  well-defined,  localised,  epileptiform  convulsions  of  dis- 
tinct Jacksonian  t}^e  is  usually  due  to  the  direct  irritation  pro- 
duced by  a  localised  "  coarse "  lesion.  It  cannot  of  course  be 
denied  that  lesions  outside  the  motor  area  may  and  do  produce 
localised  discharges  (either  through  the  vascular  alterations  which 
they  cause,  or  reflexly,  as  described  above,  see  page  78) ;  but  I  very 
much  doubt  if  localised  epileptiform  convulsions,  such  as  I  am  now 
referring  to,  are  frequently  produced  in  this  way  {i.e.,  by  a  distant 
lesion,  which  does  not  directly  irritate  the  portion  of  grey  matter,  the 
discharge  of  which  is  the  cause  of  the  spasm). 

Further,  a  localised  paralysis  (like  a  localised  convulsion)  may  be 
caused  by  the  vascular  changes  produced  by  a  tumour  outside  the 
motor  area. 

On  the  other  hand,  it  is  important  to  note  that  slow  destruction 
of  motor  grey  matter  is  often  unattended  with  symptoms,  i.e.,  unaccom- 
panied by  paralysis ;  but  irritation  of  motor  grey  matter  (provided 
that  it  is  sufficiently  intense  to  excite  discharge,  and  that  the  way  out 
for  that  discharge  is  open)  of  necessity  produces  spasms. 

Again,  a  localised  paralysis  may  result  from  a  lesion  in  any  part 
of  the  neuro-motor  apparatus  (centres,  conductors,  peripheral  nerves), 
and  it  is  not  always  easy  to  determine  the  exact  point  at  wliich  that 
lesion  is   situated  ;    but   localised   epileptiform   convulsions   of  the 


LOCALISED  EPILEPTIFORM  CONVULSIONS.  85 

Jacksonian  type  are  very  generally,  I  believe,  due  to  a  discharge  of 
motor  grey  matter  in  the  cerebral  cortex.  In  rare  cases  a  lesion  of 
the  internal  capsule  is  so  limited  in  extent  that  a  localised  paralysis, 
say  of  the  face  (as  in  Hughes  Bennett's  case),  is  alone  produced ;  it 
would  be  very  difficult,  and  in  many  cases  probably  impossible,  to 
distinguish  such  a  paralysis  from  that  due  to  a  cortical  lesion. 

I  am  disposed,  therefore,  to  think,  on  the  one  hand,  that  localised 
epileptiform  convulsions  of  the  true  Jacksonian  type  are  more 
certainly  produced  by  a  discharging  lesion  in  the  motor  area  of  the 
cortex,  than  localised  paralysis  by  a  destroying  lesion.  But,  on  the 
other  hand,  I  am  prepared  to  grant  that  when  a  localised  paralysis 
due  to  a  cortical  lesion  is  present,  it  is  more  certainly  indicative  of 
the  exact  seat  of  the  lesion  than  a  localised  convulsive  seizure. 

Irritation  and  discharge  indicate  that  the  affected  portion  of  grey 
matter  is  situated  in  the  neighbourhood  of,  rather  than  at  the  exact 
seat  of  the  lesion,  while  paralysis  shows  that  the  affected  portion  of 
grey  matter  is  actually  involved  by  the  new  growth. 

Further,  it  may  probably  be  granted  that  a  lesion  outside  the 
motor  area  is  more  apt  to  produce  irritation  than  inliibifcion  of  a 
motor  centre — in  other  words,  is  more  likely  to  be  attended  with 
spasms  than  paralysis. 

Tonic  spasms,  which  most  commonly  affect  the  muscles  of  the 
back,  but  which  in  some  cases  also  involve  the  muscles  of  the  limbs, 
and  which  are  in  many  instances  accompanied  by  retraction  of  the 
head,  occur  in  some  cases  of  intracranial  tumour.  In  some  cases,  the 
spasmodic  contractions  are  continuous,  and  produce  more  or  less 
persistent  rigidity ;  in  others,  they  occur  in  paroxysms,  or  the  con- 
tinuous spasms  are  associated  with  paroxysmal  exacerbations,  and  a 
condition  not  unlike  tetanus  is  produced. 

Spasms  of  this  description  possess  some  localising  value  ;  for  the 
tumours,  with  which  they  are  associated,  are  usually  subtentorial,  and 
are  often  situated  in  the  middle  lobe  of  the  cerebellum. 

Dr.  Hughlings  Jackson  believes  that  spasms  of  this  kind  are 
the  result  of  a  discharge  of  grey  matter  in  the  cerebellum  itself. 
Dr.  Sharkey  thinks  that  the  persistent  rigidity  is  due  to  the  effects  of 
irritative  pressure  upon  the  pyramidal  tracts  in  the  pons  Varolii  or 


86  ANALYSIS  OF  INDIVIDUAL  SYMPTOMS. 

medulla  oblongata;  while  he  believes  that  the  tetanic  convulsive 
seizures  are  caused  by  irritation  of  grey  matter  in  the  floor  of  the 
fourth  ventricle.  I  have  long  taught  that  a  cerebellar  tumour  may 
produce  tonic  spasms,  either  persistent  or  intermittent,  by  pressing 
upon  and  irritating  the  tissues  of  the  pons  Varolii  or  medulla  oblongata 
(both  the  fibres  of  the  pyramidal  tract  and  the  grey  matter  throughout 
the  pons,  and  not  merely  the  grey  matter  in  the  floor  of  the  fourth 
ventricle).  In  support  of  this  view,  I  have  been  in  the  habit  of  men- 
tioning the  fact  that  in  large  subtentorial  tumours,  such  as  tumours 
of  the  cerebellum,  the  pons  A^arolii  and  medulla  oblongata  are  usually 
after  death  compressed,  flattened,  softened,  and  oedematous. 

In  some  cases,  tetanic-like  seizures  of  this  description  are  associ- 
ated with  inflammatory  changes  in  the  membranes  at  the  posterior 
part  of  the  base  of  the  brain.  In  such  cases  the  spasms  are,  I  believe, 
often  due  to  secondary  changes  produced  in  the  pons  and  medulla. 

CONTEACTUEES,  ChOEEIC  SpASMS,  &C. 

The  common  forms  of  contracture,  such  as  are  associated  with 
ordinary  hemiplegia,  may  of  course  be  present  in  those  cases  in 
which  the  tumour  involves  the  motor  (pyramidal)  tract,  and  in 
which  secondary  descending  degeneration  results.  Hysterical  con- 
tractures may  doubtless  occur  in  those  cases  of  intracranial  tumour 
in  which  hysterical  symptoms  are  prominent,  but  no  case  of  the  kind 
has  come  under  my  own  observation.  Possibly,  too,  persistent  spasm 
and  contracture  (resembling  that  produced  by  Duret  in  the  lower 
animals)  may  result  from  irritation  in  the  dura  mater. 

Choreic  spasms  are  extremely  rare  in  cases  of  intracranial  tumour. 
IMiUs  and  Lloyd  state  that  in  one  of  Petrina's  cases,  a  glioma  involv- 
ing the  substance  of  both  frontal  lobes,  choreic  movements  of  the 
right  arm  were  present :  in  that  case  tremor  in  both  arms  was 
also  a  symptom.  1  Wood  states  that  the  choreic  spasms  of  cerebral 
syphilis  may  assume  a  distinctly  choreic  type.- 

Bhythmical  movements,  circus  movements,  and  forced  movements  are 
also  exceedingly  rare.     They  may  be  expected  to  be  present  in  some 

^  Pepper's  Sijstem  of  Medicine,  vol.  v.,  p.  1040. 
-  Ibid.,  p.  1011. 


CONTRACTURES,  CHOREIC  SPASMS,  ETC.  87 

of  the  cases,  in  which  the  tumour  involves  the  middle  peduncle  of  the 
cerebellum,  the  pons  Varolii,  or  ISTothnagel's  nucleus  cursarius  in  the 
corpus  striatum. 

A  reding  gait,  resembling  that  due  to  intoxication,  is  an  important 
symptom  in  many  cases  of  cerebellar  tumour,  as  I  shall  afterwards 
more  fully  point  out. 

The.  tremor,  associated  with  voluntary  movement,  which  resembles 
that  of  cerebro-spinal  sclerosis,  has  already  been  alluded  to. 

The  condition  of  the  Madder  and  rectum  in  cases  of  intracranial 
tumour  calls  for  no  special  remarks.  Exactly  the  same  modifications 
.  in  these  reflexes  which  are  met  with  in  other  forms  of  cerebral  lesion 
(such  as  unconscious  urination  or  retention  of  urine  in  coma)  may 
occur  here. 

Tumours  in  the  lower  part  of  the  pons  Varolii  and  in  the  medulla 
oblongata  seem  in  some  instances  to  be  attended  with  more  decided 
alterations  in  the  urinary  and  rectal  reflexes  than  tumours  which 
are  situated  higher  up. 


CHAPTER    V. 

SENSOEY  DEEANGEI^iENTS— TOUCH— SIGHT— HEARi:^G— 
TASTE— SMELL. 

Disorders  of  Sensation. 

The  derangements  of  sensation  which  occur  in  the  course  of  intra- 
cranial tumours  are  (with  the  exception  of  headache)  usually  less, 
prominent  and  persistent  symptoms  than  the  corresponding  derange- 
ments of  motion. 

Derangements  of  the  Sensibility  of  the  Skin. 

Derangements  of  the  sense  of  touch  are  of  frequent  occurrence,  and 
may  be  either  in  the  direction  of  diminished  or  increased  functions. 

Anaesthesia. — The  extent  and  distribution  of  the  tactile  impair- 
ment which  may  be  present  is  subject  to  great  variations,  and 
depends  upon  the  position  of  the  tumour,  and  the  exact  manner  in 
which  the  anaesthesia  is  produced. 

In  some  cases,  in  which  the  anaesthesia  is  widely  distributed  and 
not  very  profound,  the  impairment  is  due  to  a  general  depression  of 
the  cerebral  (perceptive)  centres  rather  than  to  any  localised  derange- 
ment of  the  tactile  centres.  This  form  of  anaesthesia  is  frequently 
met  with  in  the  later  stages  of  intracranial  tumours.  In  the  earlier 
stages,  anaesthesia  due  to  this  cause  is  seldom  considerable,  though  I 
liave  known  it  sufficiently  great  to  completely  mask  the  pain  of  a 
scrofulous  affection  of  the  wrist  joint.  ^ 

In  other  cases  the  anaesthesia  is  half-sided  in  distribution.  In 
such  cases  the  hemi-antesthesia  is  usually  combined  with  hemiplegia, 
and  the  tumour  is  (generally)  so  placed  as  to  involve  the  posterior 
third  of  the  posterior  division  (or  sensory  portion)  of  the  internal 
capsule ;  but  it  may  be  situated  above  or  below  this  point.     Large 

*  See  a  case  of  scrofulous  tumour  of  the  cerebellum,  reported  in  the  Edbiburgh 
Medical  Journal  for  June  1879,  p.  1073. 


ANESTHESIA.  89 

cortical  or  subcortical  tumours,  which  involve  the  sensory  fibres  of 
the  internal  capsule  as  they  pass  to  the  tactile  centre  of  the  cortex, 
may  also  produce  hemi-ansesthesia. 

Tumours  involving  the  hippocampal  region  and  the  gyrus  fornicatus 
should,  if  Terrier  and  Schafer  are  correct  in  thinking  that  the  centre 
for  touch  is  situated  in  these  parts  of  the  brain,  be  attended  with 
hemi-ansesthesia  on  the  opposite  side  of  the  body. 


Fig,  20. — The  under  surface  of  the  left  hemisphere  of  the  brain  of  a 
monkey,  showing  a  lesion  causing  complete  anaesthesia  of  the  opposite  side 
of  the  body.     (After  Ferrier.) 

Terrier  places  the  centre  for  the  sense  of  touch  in  the  hippocampal 
region;  he  found  that  destruction  of  this  part  of  the  brain  in  the 
monkey  (see  Fig.  20)  was  followed  by  hemi-ansesthesia  on  the  opposite 
side  of  the  body. 

Horsley,  Schafer,  and  Sanger  Brown  found  that  destruction  of 
the  gyrus  fornicatus  produced  hemi-ansesthesia  on  the  opposite 
side;  and  this  loss  of  sensibility  seemed  to  be  permanent.  But 
"  whether,"  says  Schafer,  "  the  perception  of  tactile  and  general  sen- 
sibility is  confined  to  the  gyrus  fornicatus  and  its  continuation  into 
the  gyrus  hippocampus,  can  only  be  effectually  cleared  up  by  the 
entire  removal  of  these  parts  of  the  limbic  lobe — an  operation  of  the 
greatest  difficulty,  but  one  which  I  have  not  given  up  hopes  of  ulti- 
mately effecting.  In  the  meantime,  I  would  affirm  the  extreme  pro- 
bability of  this  hypothesis  on  evidence  obtained  by  exclusion,  for  I 


90  ANALYSIS  OF  INDIVIDUAL  SYMPTOMS. 

liave  never  been  able  to  determine  the  existence  of  any  permanent 
diminution  of  sensibility  after  operations  upon  other  parts  of  the 
cortex,  unless  there  were  a  possibility  of  the  limbic  lobe  having  been 
directly  or  indirectly  involved."  ^ 

Whether  tumours  which  destroy  the  motor  area  of  the  cortex  pro- 
duce any  loss  of  tactile  sensibility  in  the  parts  which  are  paralysed 
is  a  disputed  point.  Charlton  Bastian  and  some  other  authorities 
think  that  some  degree  of  aniesthesia  is  often  produced  in  this  way ; 
and  I  myself  have  met  with  cases  which  seem  to  lend  support  to 
their  view.- 

Alternate  hemi-anaesthesia  (loss  of  tactile  sensibility  in  tlie  limbs 
on  the  opposite,  and  in  the  face  on  the  same  side  as  the  lesion) 
has  already  been  referred  to.  As  previously  stated,  it  is  generally 
accompanied  by  hemiplegia,  and  may  be  caused  by  a  tumour  in  the 
pons  Varolii. 

Localised  anaesthesia  in  the  territory  supplied  by  the  fifth  nerve 
should  be  carefully  looked  for  in  all  cases  of  intracranial  tumour. 
When  present,  it  is  a  valuable  localising  symptom,  analogous  to 
the  paralysis  which  is  limited  to  the  muscles  supplied  by  a 
cranial  nerve. 

Hypermstliesia  (excluding  headache,  wliich  has  already  been  de- 
scribed) has  seldom  been  a  prominent  symptom  in  the  cases  of  intra- 
cranial tumour  which  have  come  under  my  notice.  The  experience 
of  Mills  and  Lloyd  seems  different,  for  they  state,  "  hypereesthesia 
occurs  so  commonly  as  to  be  almost  regarded  as  a  general  symptom 
of  brain  tumours.  Sometimes  it  is  confined  to  the  head ;  sometimes 
it  is  generally  diffused ;  more  frequently  it  is  present  in  the  limb  or 
limbs  affected  with  the  paralysis.  With  hypersesthesia  the  patients 
often  complain  of  spontaneous  pain  in  the  limbs."  ^ 

Neuralgic  pains,  with  or  without  hyperesthesia  of  the  face  or 
scalp,  are  of  frequent  occurrence.  When  strictly  limited  to  the  area 
of  distribution  of  the  fifth  nerve,  they  are  of  localising  value ;  and 
this  is  more  especially  the  case  when  all  three  branches  of  the  nerve 

1  "  Experiments  on  Special  Sense  Localisation  in  the  Cortex  Cerebri  of  the  Monkey. " 
by  E.  A.  Schiifer,  E.R.S.  :  Brain,  January  1888,  p.  379. 

2  See,  for  example,  a  case  reported  in  the  Edinburgh  Medical  Journal,  August  1878, 
p.  144. 

8  Pepper's  System  of  Medicine,  vol.  v.,  p.  1042. 


DERANGEMENTS  OF  THE  SENSE  OF  SIGHT.  91 

appear  to  be  involved  ;  in  such  cases  there  is  reason  to  suspect  involve- 
ment of  the  trunk  of  the  nerve  within  the  cavity  of  the  cranium. 


Derangements  of  the  Sense  of  Sight. 

Derangements  of  the  sense  of  sight  are  frequently  associated  with 
intracranial  tumours.  The  most  common  alteration  is  the  dimness  of 
vision  (diminished  acuity  and  restricted  field),  which  is  so  frequently 
met  with  in  the  later  stages  of  double  optic  neuritis,  and  with  post- 
neuritic atrophy. 

All  degrees  of  impairment,  from  the  slightest  loss  of  visual  acute- 
ness  up  to  complete  blindness,  are  met  with. 

The  state  of  vision  in  those  cases  of  intracranial  tumour  in  which 
there  is  optic  neuritis  is  of  so  much  importance  that  no  apology  is 
necessary  for  referring  to  several  points  which  have  already  been 
mentioned  in  a  previous  chapter. 

The  fact  that  in  the  earlier  stages  there  is  often  no  impairment, 
either  of  the  acuteness  or  of  the  field  of  vision,  has  been  previously 
emphasised. 

In  most  cases  in  which  the  papillitis  remains  for  any  time,  more 
or  less  impairment,  and  in  some  cases  total  loss  of  vision,  result. 
This  is  not  always  so,  for  cases  are  occasionally  met  with,  in  which 
even  after  well-marked  optic  neuritis  has  persisted  for  a  long  time 
(Aveeks  or  even  months)  vision  has  remained  good.  In  connection 
with  this  aspect  of  the  subject,  it  is  important  to  remember  that  the 
inflammation  of  the  optic  discs  can  in  many  cases  be  most  beneficially 
influenced  by  treatment.  This  is  more  especially  the  case  when  the 
cerebral  lesion  is  syphilitic.  In  such  cases  sight  may  be  perfectly, 
or  almost  perfectly,  restored  after  the  patient  has  been  completely 
bUnd ;  and  some  authorities  think  that  even  in  non-syphilitic  cases  of 
brain  tumour,  double  optic  neuritis  with  total  bhndness  may  be  so 
completely  recovered  from,  that  vision  becomes  perfect,  and  little  or 
no  perceptible  ophthalmoscopic  alterations  remain.  In  my  own  ex- 
perience, when  a  patient  suffering  from  cerebral  tumour  becomes 
completely  blind,  in  consequence  of  double  optic  neuritis,  recovery 
is  usually  imperfect  even  in  syphilitic  cases.  In  ahnost  all  the 
cases  of  cerebral  tumour,  with  double  optic  neuritis  and  total  loss  of 


92  ANAL  YSIS  OF  INDIVID  UAL  S  YMPTOMS. 

vision,  which  have  come  under  my  observation,  some  defect  of  vision 
has  persisted  (see  Figs.  21  and  22),  and  some  alterations  in  the 
fundus,  which  could  be  detected  with  the  ophthalmoscope,  have 
remained. 


Fig.  21. — Perimeter  chai-t  of  the  fields  of  vision,  showing  peripheral 
constriction,  the  result  of  former  optic  neuritis,  in  a  case  of  intracranial 
syphilis. 


Fig.  22. — -Perimeter  chart  of  the  fields  of  vision  for  white  showing 
marked  contraction  of  the  right  and  some  contraction  of  the  left  field,  the 
result  of  old  papillitis  in  a  case  of  intracranial  syphilis. 

In  most  cases  of  optic  neuritis  in  which  vision  becomes  impaired 
the  loss  is  slowly  and  gradually  established ;  but  in  some  the  loss  of 
sight  is  rapid  or  even  sudden.  In  a  case  of  scrofulous  tumour  of  the 
cerebellum,  which  I  have  already  referred  to,  sight  and  hearing  were 


HEMIANOPSIA.  93 

both  suddenly  lost,  the  patient  remaining  completely  blind  and  deaf 
during  the  whole  subsequent  period  of  the  case. 

In  some  cases,  again,  there  is  temporary  loss  of  vision.  With 
reference  to  this  point  Dr.  Hughlings  Jackson  states,  "  In  some  cases 
of  optic  neuritis  the  sight  fails  for  a  time  totally  or  partially,  although 
at  most  times  it  is  good.  The  patient  may  be  able  to  read  the  smallest 
type,  and  yet  occasionally  for  a  few  minutes  become  quite  blind."  ^ 

The  dimness  of  vision  which  is  the  result  of  double  optic  neuritis 
in  cases  of  intracranial  tumour,  since  it  is  due  to  a  peripheral  change 
which  may  be  produced  by  a  tumour  in  any  part  of  the  cranial  cavity, 
has  no  localising  value. 

Blindness  due  to  primary  optic  atrophy  is  occasionally,  but 
rarely,  met  with  in  cases  of  intracranial  tumour.  When  it  does  occur, 
it  is  usually  due  to  the  pressure  of  the  tumour  upon  the  optic  chiasma, 
or  upon  the  optic  nerve  trunks  in  front  of  the  chiasma.  In  one  most 
interesting  case,  which  was  sent  to  me  by  Dr.  Berry,  and  which  is 
still  under  observation,  bilateral  temporal  hemianopsia  without  optic 
neuritis  first  developed,  and  in  the  course  of  time  was  followed  by 
complete  blindness  and  general  atrophy  of  both  discs. 

Hemiano'psia  is  sometimes  met  with  in  cases  of  intracranial 
tumour,  and  is  an  important  localising  symptom. 

The  most  common  variety — lateral  or  homonymous  hemianopsia 
— may  be  due  to  a  lesion  (1)  in  any  part  of  the  visual  tract  behind  the 
optic  chiasma,  optic  tract — -posterior  part  of  the  internal  capsule, 
visual  conducting  fibres,  as  they  pass  through  the  centrum  ovale  to 
join  the  visual  centre  in  the  cortex ;  or  (2)  of  the  visual  centre  itself, 
i.e.,  the  grey  matter  of  the  occipital  lobe. 

A  lesion  (tumour)  involving  the  left  visual  tract,  behind  the 
chiasma,  produces  blindness  in  the  left  side  of  each  retina,  or,  in 
other  words,  is  attended  with  right-sided  homonymous  hemianopsia. 
In  the  case  of  a  left-sided  lesion,  the  patient  is  consequently  unable 
to  see  objects  on  his  right.  Vice  versa,  a  right-sided  lesion  produces 
left-sided  homonymous  hemianopsia. 

The  exact  character  of  the  hemianopsia,  as  shown  by  careful  peri- 
meter measurements,  differs  considerably  in  different  cases.  In 
some,  the  divisional  line  passes  right  down  through  the  centre  of  the 

^   Transactions  of  the  OpJithalmological  Society  of  the  United  Kingdom,  vol.  i.,  p.  70. 


94 


ANALYSIS  OF  INDIVIDUAL  SYMPTOMS. 


field,  the  fixing-point  being,  however,  usually  spared. — (See  I'ig.  23.) 
In  consequence  of  this  fact,  central  vision  in  cases  of  homonymous 
hemianopsia  is  usually  good. 


Fig.  23. — Perimeter  chart  of  the  fields  of  vision  in  a  case  of  left-sided 
homonymous  hemianopsia,  which  was  in  all  probability  due  to  an  old 
cortical  lesion  of  the  posterior  part  of  the  right  visual  centre. 

The  defect  of  vision  does  not,  it  will  be  observed,  come  quite  up  to  the 
middle  line.  There  is  absolutely  no  contraction  of  the  sound  (seeing)  haK 
of  the  field  in  either  eye — a  remarkable  contrast  with  the  cases  represented 
in  rigs.  24  and  25.  In  the  shaded  portion  of  the  left  half  of  the  left  field 
(to  which  the  letter  A  points)  the  loss  of  vision  was  not  absolute. 

In  other  cases  the  contraction  of  the  ^dsual  field  is  not  limited  to 
the  side  of  the  hemianopsia,  but  involves  more  or  less  of  the  peripheral 
pcDition  of  the  opposite  (seeing)  halves  of  the  fields.  This  peripheral 
coijistriction  of  the  seeing  half  of  the  retina  is  usually,  so  far  as  I 
kno\v,  greater  on  the  side  of  the  cerebral  lesion.  Thus  a  lesion  in  the 
left  hemisphere,  which  produces  right-sided  hemianopsia,  with  peri- 
phreral  constriction  of  the  left  half  of  each  visual  field,  will  produce 
m;uch  greater  constriction  of  the  left  half  of  the  left  field  than  of  the 
left  half  of  the  right.— (See  Figs.  24  and  25.) 

The  exact  significance  of  this  peripheral  constriction,  in  the  seeing 
halves  of  each  retina,  which  is  greater  in  that  on  the  same  side  as 
the  lesion,  is  not  very  clear.  It  may  apparently  be  caused  by  a  lesion 
which  is  situated  in  the  neighbourhood  of  the  internal  capsule  as  well 
as  by  a  lesion  which  involves  the  cortical  visual  centres.  I  am  dis- 
posed, provisionally,  to  think  that  when  it  results  from  a  lesion  of 
the  cortical  centres,  the  lesion  is  situated  farther  forwards — i.e.,  more 


HEMIANOPSIA. 


95 


in  the  neigliboiirhood  of  the  angular  gyrus — rather  than  in  that  part 
of  the  ^dsual  centre  which  is  situated  in  the  tip  of  the  occipital  lobe, 
and  which  has  been  termed  the  "  half- vision  "  centre. 


Fig.  24. — Perimeter  charts  of  the  fields  of  vision  for  white  in  a  case  of 
temporary  right  -  sided  hemiplegia  and  hemi-ansesthesia,  showing  partial 
right-sided  homonymous  hemianopsia ;  some  peripheral  contraction  of  the 
whole  field  in  the  left  eye  (the  parts  to  which  the  letters  A  and  B  point) ;  and 
contraction  of  the  upper  part  of  the  left  half  of  the  right  field  (the  part  to 
which  the  letter  6'  points).  Over  the  dotted  area  to  which  the  letter  D 
points  the  field  extends  beyond  the  nominal  average. 


Fig.  25. — Perimeter  charts  of  the  fields  of  vision  for  white  in  a  case  of 
left-sided  hemiplegia,  showing  left-sided  homonymous  hemianopsia  ;  con- 
siderable peripheral  contraction  of  the  whole  field  in  the  right  eye  (the  part 
to  which  the  letters  A  and  B  point)  ;  and  contraction  of  the  upper  part  of 
the  right  half  of  the  left  field  (the  part  to  which  the  letter  C  points). 

The  exact  construction  of  the  visual  centre,  and  the  relationship 
of  the  two  visual  centres  to  the  two  eyes  and  to  one  another,  is 


96 


ANALYSIS  OF  INDIVIDUAL  SYMPTOMS. 


undoubtedly  very  complicated,  and  not  yet  thoroughly  understood. 
It  seems,  however,  well  established  that  visual,  like  all  other  sensory 
impressions  (with  perhaps  the  single  exception  of  those  proceeding 
to  the  smell  centre),  pass  up  to  the  opposite  side  of  the  brain ;  in 
other  words,  visual  impressions  of  objects  on  the  right  hand  side  of 


Fig.  26. — Scheme  of  the  optic  tracts  and  visual  centres.  (After 
Ferrier. ) 

A  the  right,  and  A '  the  left  angular  gyrus  ;  C,  optic  chiasma ;  E  the 
right,  and  E'  the  left  eye  ;  i\^  the  right,  and  JS!'  the  left  optic  nerve ;  0  the 
right,   and  0'  the   left  occipital   lobe  ;  T  the  right,  and  T  the  left  optic 

tract.     The  thin  continuous  line represents  the  retinal  relations  of  0  ; 

the  thick  continuous  line  represents  the  retinal  relations  of  0' ;  the  inter- 
rupted line  -  -  -  indicates  the  retinal  relations  of  A ,  and  the  dotted  line  ...... 

the  retinal  relations  of  A '.  The  relations  of  A  and  A '  with  the  eye  on  the 
same  side  are  indicated  by  finer  interrupted  and  dotted  lines  respectively. 

the  middle  line,  which  are  received  on  the  left  half  of  each  retina, 
pass  up  to  the  left  hemisphere  of  the  brain;  visual  impressions  of 
objects  on  the  left  side  of  the  middle  line,  which  are  received  on  the 
right  half  of  each  retina,  pass  up  to  the  right  hemisphere.  In  order 
that  this  may  be  effected,  the  nerve  fibres  passing  from  the  inner 
(nasal)  half  of  each  retina  decussate  in  the  chiasma ;  in  other  words, 
visual  impressions  which  are  seen  to  the  right  by  the  right  eye, 
and  visual  impressions  which  are  seen  to  the  left  by  the  left  eye. 


HEMIANOPSIA.  97 

decussate ;  while  visual  impressions  which  are  seen  to  the  left  by  the 
right  eye,  and  those  which  are  seen  to  the  right  by  the  left  eye,  do 
not  decussate. — (See  Fig.  26.) 

But  further,  the  fact  that  in  cases  of  lateral  or  homonymous 
hemianopsia  there  is  no  loss  of  central  vision,  together  with  the 
results  of  experimental  observations  on  the  visual  centres  in  the 
lower  animals,  seems  to  show  that  the  visual  impressions  which 
impinge  on  the  fixing-point  pass  up  to  eacli  cerebral  hemisphere  ; 
and  that  the  visual  centres  in  each  hemisphere  are  connected  in  a 
complicated  manner. 

Temijoral  hemianopsia  (see  Figs.  27  and  28)  is  comparatively 
rare.  In  it  the  inner  (nasal)  side  of  each  retina  is  blind,  and  the 
patient  is  unable  to  see  objects  on  the  left  of  the  middle  line  with 
the  left  eye,  and  on  the  right  of  the  middle  line  with  the  right  eye. 
Since  central  vision  may  be  unimpaired,  and  objects  on  the  right  of 
the  middle  line  can  be  seen  by  the  left  eye,  and  objects  on  the  left 
of  the  middle  line  by  the  right  eye,  the  visual  defect  may  either  be 
unnoticed  by  the  patient,  or  it  may  attract  comparatively  little  atten- 
tion; in  many  cases,  in  fact,  it  is  only  discovered  when  the  visual 
fields  are  tested  by  the  physician.  This  form  of  hemianopsia  is 
almost  always  due  to  pressure  on  the  centre  of  the  chiasma;  and 
the  cause  of  the  pressure  is  very  generally  a  new  growth  of  the 
pituitary  body  (such  as  is  represented  in  Figs.  49  and  50),  an 
aneurism  of  one  of  the  arteries  forming  the  anterior  part  of  the  circle 
of  Willis,  or  a  syphilitic  gumma  in  the  fore  part  of  the  interpedun- 
cular space.  Probably  in  some  cases  bilateral  temporal  hemianopsia 
is  due  to  a  localised  meningitis  involving  the  centre  of  the  chiasma. 

In  Fig.  26  the  arrangement  of  the  visual  fibres  suggested  by 
Ferrier  is  shown.  Ferrier  believes  that  the  visual  centre  is  very 
extensive,  and  is  situated  both  in  the  angular  gyrus  and  occipital 
lobe.  Schafer's  recent  experiments  are  opposed  to  some  of  Ferrier's 
results.  Schafer  did  not  observe  any  visual  defect  whatever,  after 
destruction  of  the  angular  gyrus;  he  found,  however,  that  destruc- 
tion of  one  occipital  lobe  is  followed  by  immediate  and  persistent 
hemianopsia,  and  that  the  complete  removal  of  both  occipital  lobes 
is  followed  by  total  and  persistent  blindness,  as  Munk  also  found.  ^ 

1  Brain,  January  1888,  p.  363  et  seq. 
G 


98 


ANALYSIS  OF  INDIVIDUAL  SYMPTOMS. 


Nasal  hemianopsia  is  exceedingly  rare.  In  it  the  outer  half 
of  each  retina  is  blind  (see  Fig.  29),  and  the  patient  is  unable  to 
see  objects  on  the  left  side  of  the  middle  line  with  the  right  eye, 
and   on  the  right  side  of   the  middle   line  with  the   left.      Nasal 


Fig.  27. — Perimeter  chart  showing  temporal  hemianopsia  in  a  case  of 

enormouB  aneurism  of  the  right  internal  carotid  artery. — (See  Fig.   55.) 
The  chart  was  taken  by  Dr.  Berry  on  November  29,  1883. 


Fig.  28. — Perimeter  chart  showing  partial  temporal  hemianopsia 
in  a  man  aged  fifty-six.  The  cause  of  the  condition,  which  completely 
passed  off  under  large  doses  of  iodide  of  potassium,  was  very  obscure.  The 
patient,  who  denied  syphilis,  complained  of  constant  dull  frontal  head- 
ache, stupidity,  loss  of  memoi-y,  and  inability  to  exert  himself.  The  radial 
pulse  was  84. 

hemianopsia  can  only  be  caused  by  a  lesion  which  involves  each  outer 
side  of  the  chiasma.  leaving  the  centre  and  fore  part  of  the  chiasma 


HEMIANOPSIA. 


99 


free.  It  is  theoretically  possible  that  two  independent  tumours 
might  be  so  symmetrically  placed  as  to  produce  such  a  condition  ;  but, 
so  far  as  I  am  aware,  no  such  cases  have  been  met  with.  It  is  very 
unhkely  that  a  single  tumour  could  produce  this  form  of  hemianopsia, 
i.e.,  could  involve  each  outer  side  of  the  chiasma  without  involving  the 
centre  too.  This  rare  condition  is  usually  caused  by  the  pressure 
of  a  symmetrical  enlargement  of  each  internal  carotid  artery,  or  a 
symmetrically  placed  focus  of  inflammation. 


'^^  .J~  '65 


Fig.  29. — Nasal  hemianopsia. 

Unilateral  optic  neuritis,  with  or  without  dimness  of  vision,  may, 
as  has  been  previously  stated,  be  due,  in  rare  and  exceptional  cases, 
to  an  intracranial  tumour ;  but  in  the  vast  majority  of  cases  in  which 
this  condition  and  in  which  unilateral  optic  atrophy  occur,  the 
lesion  is  situated  within  the  cavity  of  the  orbit.  When  the  optic 
neuritis  is  due  to  the  last-mentioned  cause,  some  of  the  muscles  of  the 
affected  eye  are  generally  paralysed  from  implication  (within  the 
cavity  of  the  orbit)  of  the  nerve  trunks  which  supply  them ;  and  in 
many  cases  protrusion  of  the  eyeball,  or  other  local  evidence  of  the 
presence  of  an  intra-orbital  lesion,  is  present. 

Temporary  lateral  or  homonymous  hemianopsia  is  common  in 
cases  of  migraine ;  and  when  an  intracranial  tumour  is  complicated,  as 
it  may  be  by  migraine,  this  symptom  may  of  course  be  present. 

A  discharging  lesion  of  the  visual  centre  in  one  hemisphere  (say  a 
syphilitic  gumma  on  the  surface  of  the  occipital  lobe)  should  theoreti- 


loo  ANALYSIS  OF  INDIVIDUAL  SYMPTOMS. 

cally  be  manifested  externally  by  flashes  of  light,  seen  on  one  side  of 
the  middle  line,  but,  as  we  might  expect,  usually  referred  by  the 
patient,  to  the  eye  corresponding  to  that  side  of  the  middle  line  to 
which  the  flashes  of  light  are  projected.  A  discharging  lesion  of  the 
left  half-vision  centre  would,  for  instance,  produce  discharge  of  nerve 
cells  connected  with  the  left  half  of  each  retina  ;  and  this  discharge 
would  be  represented  in  consciousness  by  a  bright  light  seen  on  the 
right  side  of  the  middle  line,  and  therefore  very  usually  thought  by 
the  patient  (ignorant  of  the  construction  of  the  visual  mechanism)  to 
be  seen  with  the  right  eye. 

Discharges  of  this  kind  are  comparatively  common  in  cases  of 
epilepsy,  and  constitute  one  of  the  forms  of  visual  aura ;  but,  so  far  as 
I  know,  they  have  been  very  rarely  observed  as  isolated  phenomena 
(i.e.,  without  epilepsy,  without  being  followed  by  unconsciousness,  or 
unconsciousness  and  epileptiform  convulsions). 

Two  cases  have,  however,  come  under  my  own  observation.  In 
the  first — a  case  of  melanotic  sarcoma,  in  which  many  sarcomatous 
nodules  were  scattered  throughout  the  brain  tissue — the  patient 
suffered,  at  short  intervals,  from  paroxysms  of  violent  headache, 
during  which  marked  vaso-motor  flushings,  alteration  in  the  pulse 
frequency,  and  sensations  of  vivid  flashes  of  light  in  the  right  eye 
occurred.  At  the  autopsy,  a  large  nodule  of  melanotic  sarcoma  was 
found  on  the  surface  of  the  tip  of  the  left  occipital  lobe  (visual  centre 
for  objects  seen  to  the  right  of  the  middle  line),  and  it  is  probable 
that  the  flashes  of  light,  which  were  referred  to  the  right  eye,  were 
the  result  of  nervous  discharges  caused  by  the  irritation  of  this  lesion. 
In  that  case  there  was  no  hemianopsia,  so  far  as  could  be  ascertained 
by  the  rough  method  of  examination  {i.e.,  without  exact  perimeter 
measurement). 

It  may  be  argued  that  the  flashes  of  light  were  in  this  case  the 
result  of  peripheral  (vaso-motor)  alterations  in  the  retinae  themselves, 
for  well-marked  double  optic  neuritis  was  present.  But  if  this  had 
been  the  case,  it  is  difficult  to  see  why  the  flashes  of  light  were 
referred  to  one  and  not  to  both  eyes.  And  again,  if  the  flashes  of 
light  were  in  this  case  due  to  local  alterations  in  the  retina,  why  are 
they  not  more  frequently  seen  in  other  cases  of  cerebral  tumour  in 
which  optic  neuritis  is  present  ?     A  satisfactory  answer  to  this  last 


TEMPORARY  HEMIANOPSIA.  loi 

question  is  perhaps  to  be  found  in  the  fact  that  vaso-motor  flushings 
are  not  common  in  cerebral  tumours ;  that  in  this  case  these  vaso-raotor 
phenomena  were  very  striking,  and  that  the  two  phenomena  (vaso-motor 
flushings  and  flashes  of  light)  were  always  associated  together ;  in 
other  words,  the  flashes  of  light  never  occurred  without  the  flushings. 
Whether  this  association  was  constant  in  the  earlier  periods  of  the 
case  I  am  unable  to  say  ;  but  the  first  symptom  which  the  patient 
experienced  was  the  sensation  of  a  bright  light  (like  the  electric  light 
— a  globe  of  bright  light)  in  the  right  eye. 

Now,  judging  from  analogy,  a  discharging  lesion  of  one  half- vision 
centre  ought  to  produce  repeated  flashes  of  light  referred  to  the 
opposite  side  of  the  middle  line  (or  by  the  patient  to  the  opposite 
eye) ;  these  discharges,  which  are  manifested  externally  by  flashes  of 
light,  should  not  be  attended  by  loss  of  consciousness,  while  they 
should  be  followed  by  temporary  homonymous  hemianopsia — (sensory 
paralysis  in  the  parts  affected  with  the  convulsion) — just  as  a 
localised  discharging  lesion  of  a  motor  centre  produces  localised 
epileptiform  convulsions,  which  are  unattended  by  loss  of  conscious- 
ness, and  which  are  followed  by  temporary  (epileptiform)  paralysis  of 
the  muscles  which  were  convulsed. 

Further,  we  might  expect  that  every  now  and  again  the  sensory, 
like  the  motor  discharge,  would  extend  to  and  involve  other  adjacent 
and  more  distant  centres  ;  and  that  the  attack  would  sometimes  cul- 
minate in  loss  of  consciousness  and  a  general  epileptiform  convulsion. 

Most  of  these  conditions  were  rigidly  fulfilled  in  my  second  case, 
which  is  reported  in  the  Edinhurgh  Medical  Journal  for  August 
1887. 

In  cases  of  hemianopsia  there  is  rarely  any  perceptible  difference 
to  be  detected  by  means  of  the  ophthalmoscope  between  the  affected 
and  sound  halves  of  the  retina. 

It  is  obvious,  from  the  statement  which  has  just  been  made,  that 
hemianopsia  is  an  important  localising  symptom.  In  all  cases, 
therefore,  of  suspected  intracranial  tumour  the  condition  of  the  fields 
of  vision  should  be  carefully  investigated ;  and  in  those  cases  in 
which  any  defect  in  the  visual  field  is  detected,  an  exact  outline  of 
the  field  should  be  carefully  mapped  out  by  means  of  the  self- 
registering  perimeter. 


102  ANALYSIS  OF  INDIVIDUAL  SYMPTOMS. 

Subjective  visual  sensations,  such  as  flashes  of  red  light,  not 
infrequently  precede  an  epileptic  fit.  The  facts  (1)  that  the  aura  is 
tlie  external  manifestation  of  a  discharge  of  grey  matter,  and  in  some 
cases  of  a  very  limited  portion  of  grey  matter,  in  the  cerebral  cortex ; 
(2)  that  by  observing  the  character  of  the  aura  we  can  in  many 
cases  form  an  opinion,  and  in  some  cases  a  very  accurate  opinion,  as 
to  the  portion  of  grey  matter  which  is  so  discharged ;  and  (3)  that  in 
cases  of  "  coarse "  cerebral  lesion  the  grey  matter  which  is  first 
discharged  {i.e.,  which  is  represented  by  the  aura)  is  usually  situated 
in  the  immediate  neighbourhood  of  the  lesion,  have  been  already 
referred  to.  They  show  the  importance  of  accurately  noting  the  exact 
character  of  any  subjective  sensations  which  may  precede  epileptiform 
seizures  in  all  cases  of  intracranial  tumour. 

Deeangements  of  the  Sense  of  Hearing. 

Deafness  is  not  often  caused  by  an  intracranial  tumour ;  when  it 
does  occur,  it  is  usually  due  to  involvement  of  the  trunk  of  the  auditory 
nerve,  either  by  the  tumour  itself  or  by  the  inflammatory  products  in 
its  neighbourhood.  In  some  cases,  loss  of  hearing  is  associated  with 
stupor  and  mental  impairment ;  in  other  words,  it  is  part  and  parcel 
of  a  general  impairment  of  the  cerebral  functions,  rather  than  of  a  lesion 
of  the  auditory  nerve  apparatus  in  particular.  Dr.  Hughlings  Jackson 
says,  mth  regard  to  this  point,  "  It  is  very  striking  that  whilst  tumours 
of  the  cerebrum  or  cerebellum  often  produce  defect  or  loss  of  sight 
of  both  eyes,  although  in  an  indirect  way,  they  never,  so  far  as  my 
experience  goes,  produce  deafness  of  either  side  in  any  way,  with 
the  exception  of  tumours  pressing  on  the  auditory  nerve,  and  those 
producing  greatly  raised  pressure  under  the  tentorium."  ^ 

The  reason  why  deafness  does  not  result  from  localised  cerebral 
lesions,  such  as  tumours,  may  possibly  be  that  the  auditory  nerve 
on  each  side  is  connected  with  both  cerebral  (auditory)  centres. 
We  have  already  seen  that,  when  the  visual  centre  on  one 
side  is  destroyed,  there  is  hemianopsia  on  the  opposite  side,  and 
(according  to  Ferrier)  no  loss  of  central  vision.  Now,  if  we  were 
in  a  position  to  map  out  the  auditory  field  in  the  same  accurate 

^   Transactions  of  the  Ophthalmological  Society,  vol,  i.,  p.  78, 


DERANGEMENTS  OF  THE  SENSE  OF  HEARING.     103 

manner  that  we  can  map  out  the  visual  field,  it  is  quite  possible  that 
in  cases  of  destruction  of  one  auditory  centre  we  might  find  that 
while  "  central  hearing,"  so  to  speak,  is  retained,  there  is  some  peri- 
pheral limitation  of  the  auditory  field.  With  the  object  of  discover- 
ing such  defects,  the  systematic  examination  of  the  patient's  capability 
of  hearing  sound  vibrations  of  different  range  might  perhaps  be  more 
thoroughly  employed  than  is  usual  at  present.  Further,  we  know 
that  destruction  of  a  portion  of  the  left  auditory  centre  may  produce 
(in  right-handed  persons)  a  special  form  of  loss  of  hearing,  i.e.,  "  word- 
deafness  ; "  just  as  destruction  of  a  portion  of  the  left  visual  centre 
may  produce  "  word-blindness."  And  Ferrier  has  shown  that,  while 
destruction  of  one  auditory  centre  (see  Fig.  30)  does  not  produce  one- 


FlG.  30. — Outline  of  the  brain  of  a  monkey,  showing  the  position  of  the 
lesion  causing  loss  of  hearing.     (After  Ferrier.) 

The  dotted  line  indicates  the  extent  of  the  surface  exposed  by  re- 
moval of  the  skull. 

The  corresponding  part  of  the  opposite  hemisphere  was  also  destroyed. 

sided  deafness,  yet  complete  destruction  of  both  auditory  centres  does 
produce  total  deafness  in  both  ears. 

Just  as  this  chapter  was  going  to  press,  Schafer's  paper  on  Special 
Sense  Localisation  appeared.  The  results  which  he  records  are  very 
different  from  those  obtained  by  Ferrier.  Schafer  did  not  obtain  in 
any  of  his  experiments  unmistakeable  evidence,  nor  indeed  any 
evidence  at  all,  of  the  impairment  or  abolition  of  the  senses  of  hear- 
ing, smell,  or  taste.  ^  And  he  states,  "  I  believe,  therefore,  I  am 
justified  in  asserting  that  the  supposed  localisation  of  the  auditory 

1  Brain,  January  1888,  p.  262. 


I04  ANALYSIS  OF  INDIVIDUAL  SYMPTOMS. 

perceptive  faculties  in  the  temporal  lobe  in  monkeys  has  no  experi- 
mental evidence  in  its  favour;  and  the  case  I  have  described,  in  which 
both  temporal  lobes  (including  the  corona  ammonis)  were  wholly- 
removed  without  any  permanent  diminution  in  the  acuteness  of  hear- 
ing, bears  strongly  against  that  view." 

It  is  not  perhaps  unreasonable  to  suppose  that  the  plan  of  the 
auditory  and  visual  nerve  mechanisms  may  be  somewhat  similar,  and 
that  if  we  could  examine  the  condition  of  hearing  in  the  same  accurate 
and  complete  manner,  and  with  the  same  facility  that  we  can  examine 
the  condition  of  vision,  we  might  find  that  some  defect  in  hearing, 
analogous  to  hemianopsia,  does  directly  result  from  cerebral  tumours. 
But  in  the  present  uncertainty  as  to  the  position  of  the  auditory 
centre,  it  is  impossible  to  make  any  definite  statement  on  the  matter. 

The  fact  that  deafness  is  so  rarely  caused  by  intracranial  tumours, 
Avliile  loss  of  vision  (due  to  optic  neuritis  and  post-neuritic  atrophy) 
is  so  common,  seems  to  me  an  argument  against  the  view  that  the 
double  optic  neuritis  of  intracranial  tumours  is  due  to  a  neuritis 
descending  along  the  nerve  fibres,  though  it  does  not  tell  in  the  same 
strong  way  against  an  inflammatory  process  descending,  along  the 
meiiibranes,  to  the  vaginal  sheath,  and  thence  to  the  intravaginal 
portion  of  the  optic  nerve. 

Eoss  states  that  "  the  injections  of  E.  Weber  have  shown  that  there 
is  a  communication  between  the  arachnoid  cavity  and  the  labyrinth 
by  means  of  the  aqueduct  of  the  cochlea ;  and  consequently  increased 
intracranial  pressure  may  produce  an  affection  of  the  auditory 
apparatus,  similar  to  that  which  occurs  in  the  eye  under  the  same 
cu'cumstances."  I  do  not  know  on  what  clinical  grounds  he  bases 
the  latter  part  of  this  statement,  but  the  case  of  cerebellar  tumour 
(to  which  I  have  previously  referred),  in  which  both  hearing  and  sight 
were  suddenly  lost,  in  consequence  apparently  of  a  rapid  increase  in 
the  intracranial  pressure,  seems  to  lend  some  support  to  this  view, 
Be  that  as  it  may,  loss  of  hearing  is  very  rarely  indeed  associated 
with  increased  intracranial  pressure ;  the  case  just  referred  to  stands 
almost  alone ;  and  a  neuritis  of  the  end-organ  of  hearing,  with  result- 
ing deafness,  is  practically  unknown  in  cases  of  intracranial  tumour. 
This  fact  has,  however,  little  force  as  an  argument  against  the  in- 
creased pressure  theory  of  the  causation  of  optic  neuritis,  for  any 


DISORDERS  OF  THE  SENSE  OF  SMELL.  105 

communication  which  does  exist  between  the  arachnoid  cavity  and 
the  labyrinth,  through  the  aqueduct  of  the  cochlea,  must  be  very  much 
less  free  than  the  communication  between  the  arachnoid  and  the 
vaginal  space  surrounding  the  optic  nerve ;  and  it  has  yet  to  be  shown 
that  the  terminal  expansion  of  the  auditory  nerve  in  the  labyrinth  is 
constructed  so  as  to  be  injuriously  affected  {%.&.,  inflamed),  even  if 
increased  intracranial  pressure  were  brought  to  bear  upon  it  in  this 
way.  The  theory  is  nevertheless  plausible,  and,  if  we  may  suppose 
that  the  communication  between  the  arachnoid  cavity  and  labyrinth 
were  exceptionally  free,  it  is  perhaps  possible  to  account  in  this  way 
for  the  very  remarkable  and  quite  exceptional  total  deafness  in  the 
case  of  cerebellar  tumour  to  which  I  have  just  referred. 

In  more  than  one  of  my  cases  of  cerebral  tumour  the  tuning-fork 
did  not  appear  to  be  heard,  when  placed  over  certain  limited  areas  of 
the  skull,  which,  on  post-mortem  examination,  were  found  to  be 
abnormal — in  one  case  unusually  thin,  and  in  another  unusually  thick, 
owing,  to  periostitis.  Whether  this  apparent  non-conduction  of  the 
skull-sounds  only  existed  in  the  imagination  of  the  patient,  or  whether 
it  was  real,  and  if  it  did  actually  exist,  whether  it  has  any  definite 
and  localising  value,  I  am  unable  to  say.  But  the  point  is  perhaps 
worthy  of  future  investigation. 

Disorders  of  the  Sense  of  Smell. 

Derangements  of  the  sense  of  smell  are  rarely  met  with  in  cases 
of  intracranial  tumour ;  when  present,  they  are  usually  due  to  direct 
involvement  of  the  olfactory  nerves  or  olfactory  bulbs  by  the  tumour 
or  the  inflammatory  changes  in  its  neighbourhood. 

The  position  of  the  centre  for  smell  is  not  yet  definitely  deter- 
mined. Terrier  places  it  in  the  hippocampal  lobule  (see  Figs.  31  and 
32) ;  but  Schiifer  was  unable  to  detect  any  impairment  of  the  sense  of 
smell  even  after  cutting  away  the  antero-inferior  extremity  of  tlie 
temporal  lobe  on  both  sides.  ^ 

It  is  probable  that  if  we  had  the  means  of  accurately  testing  the 
range  and  field,  so  to  speak,  of  the  olfactory  sense,  impairment  of  the 
sense  of  smell  would  be  discovered  in  some  cases  of  cerebral  tumour. 

1  Brain,  January  1888,  p.  378. 


io6 


ANALYSIS  OF  INDIVIDUAL  SYMPTOMS. 


But  whether  destruction  of  any  localised  portion  of  the  brain  in  man 
produces  loss  of  smell  in  the  nostril  on  the  same  side,  or  indeed  on 
either  side,  has  not  as  yet  been  demonstrated ;  but  the  fact  that  in 
some  cases  of  hysterical  liemianaesthesia  smell  seems  to  be  abolished 


Fig.  31. 


Fig.  32. 


Figs.  31  and  32. — Lesions  of  the  right  and  left  hemisphere,  causing  loss 
of  taste  and  smelL     (After  Ferrier.) 

In  the  right  hemisphere  (31)  the  shading  indicates  the  extent  of  destruc- 
tion of  the  grey  matter.  In  the  left  (32)  the  dark  shading  indicates  the 
superficial  extent  of  the  wound  ;  and  the  dotted  lines  the  extent  of  internal 
destruction  of  the  lower  portion  of  the  temporo-sphenoidal  lobe. 

in  the  opposite  nostril,  would  appear  to  show  that  in  man  olfactory 
impressions  do  cross,  as  all  other  sense  impressions  seem  to  do,  in 
making  their  way  from  the  periphery  to  their  cerebral  (cortical) 
centre.  The  effect  which  lesions  (tumours)  involving  the  anterior 
commissure  have  on  the  sense  of  smell  has  not  perhaps  as  yet  been 
sufficiently  accurately  determined  to  permit  of  any  definite  statement. 


DiSOKDERS   OF  THE  SeNSE   OF  TaSTE. 

Derangements  of  the  sense  of  taste  have  rarely  been  noted  in 
cases  of  intracranial  tumour,  and  we  want  more  information  before 


DISORDERS  OF  THE  SENSE  OF  TASTE.  107 

we  can  speak  definitely  either  as  to  their  occurrence,  or  as  to  the 
position  of  the  lesions  which  are  likely  to  produce  thera. 

The  usually  accepted  view  is  that  the  glosso-pharyngeal  nerve  is 
the  nerve  of  taste  for  the  back  part  of  the  tongue,  and  the  chorda 
tympani  for  the  front  part. 

According  to  this  view,  subtentorial  tumours  (which  either 
directly  implicate,  or  which  produce  inflammatory  lesions  involving 
the  trunk  of  the  glosso-pharyngeal  nerve  at  the  base  of  the  brain, 
or  its  nerve  nucleus  in  the  medulla  oblongata)  should  produce  loss  of 
taste  in  the  back  of  the  tongue. 

Dr.  Gowers,  however,  disputes  this  view.  He  believes  "  that 
taste-impressions  reach  the  brain  solely  by  the  roots  of  the  fifth 
nerve ;  and  that  the  doctrine  that  the  roots  of  the  glosso-pharyngeal 
nerve  have  anything  to  do  with  taste  is  a  curious  physiological  myth, 
due  to  too  wide  an  induction  from  certain  anatomical  facts,  and  from 
dubious  experiments  on  animals.  It  is  possible,"  he  adds,  "  that  the 
nerve  fibres  for  taste  on  the  back  of  the  tongue  may  be  distributed 
with  the  glosso-pharyngeal,  reaching  them  from  the  otic  ganglion  of 
the  fifth  by  the  small  petrosal  nerve  and  tympanic  plexus.  This 
explains  the  remarkable  fact  pointed  out  by  Urbantschitsch,  and 
which  I  have  several  times  observed,  that  taste  may  be  lost  on  the 
back  as  well  as  on  the  front  of  the  tongue  in  consequence  of  caries  of 
the  walls  of  the  tympanum,"  ^ 

The  exact  position  of  the  cortical  centre  for  taste  is  undetermined. 
Ferrier  did  not  succeed  in  differentiating  any  special  region  related 
to  the  sense  of  taste,  but  thinks,  from  the  facts  which  he  did  observe, 
that  it  is  in  close  relation  with  the  olfactory  centre  {i.e.,  the  lower 
portion  of  the  temporo-sphenoidal  lobe,  or  hippocampal  lobule. — (See 
Figs.  31  and  32).     Schafer  entirely  disputes  this  view. 

It  is  probable,  I  think,  that  a  more  careful  and  systematic  exami- 
nation of  the  senses  of  smell  and  taste  than  is  at  present  usually 
adopted  will  show  that  this,  like  the  other  senses,  is  modified  in  some 
cases  of  intracranial  tumour. 

^  Diseases  of  the  Brain,  pp.  25-26. 


CHAPTER   VI. 

MENTAL  ALTERATIONS— APHASIA— APOPLECTIC  ATTACKS- 
VISCERAL  deraxge:ments. 

Mextal  Alterations. 

It  is  probable  that,  in  the  great  majority  of  cases  of  intracranial  tumour, 
some  impairment  or  derangement  of  the  mental  faculties  is  present. 

In  many  cases  the  mental  alteration  is  so  slight  that  it  can  only 
be  recognised  by  those  who  were  intimately  acquainted  with  the 
patient  before  his  illness,  and  who  are  therefore  able  to  detect  slight 
differences,  and  to  accurately  compare  the  present  with  the  previous 
(normal)  mental  state.  It  is  unnecessary  to  say  that  the  friends  and 
relatives  of  the  patient,  who  are  in  a  position  to  make  tliis  com- 
parison, often  attach  little  or  no  importance  to  slight  mental  differ- 
ences, even  if  they  notice  them. 

In  other  cases  the  mental  changes  are  so  striking  as  to  attract  the 
attention  of  even  the  most  casual  observer. 

The  mental  symptoms  and  alterations  which  may  be  present  in 
cases  of  intracranial  tumour  are  so  varied  and  numerous,  that  it  is 
difficult  to  arrange  and  classify  them,  or  to  give  an  adequate  descrip- 
tion of  them  in  a  few  lines.  Looking  at  the  matter  broadly,  it  is 
possible  to  group  the  mental  symptoms  under  one  or  other  of  the  two 
great  primary  divisions  into  which  we  have  grouped  all  nerve 
symptoms,  viz.,  irritative  or  paralytic ;  in  other  words,  into  symp- 
toms which  are  associated  with  exaltation,  or,  perhaps  better,  with 
ap^  arent  exaltation  on  the  one  hand,  and  with  diminution  of  function 
on  the  other.  The  fact  that  in  some  cases,  for  instance,  in  which  the 
symptoms  are  suggestive  of  increased  function,  as  in  some  cases  of 
mania,  the  primary  lesion  is  in  reality  paralytic,  has  already  been 
referred  to  (see  page  8). 

Amongst  the  former  {positive  symptoms,  or  those  which  are 
usually  associated   with   exaltation   of  function,  but  in  which  the 


MENTAL  ALTERATIONS. 


109 


primary   cause   is   in    many   instances   a   "  destroying "   and   not   a 
"  discharging  "  lesion),  "  alterations  in  mental  disposition,"  irritability 


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and  unevenness  of  temper,  crossness,  the  liability  to  be  upset  by 
trifles,  oddness  of  manner  or  address,  obstinate  wakefulness,  many 


I  lo  ANAL  YSIS  OF  INDIVID  UAL  S  YMPTOMS. 

emotional  and  so-called  hysterical  symptoms,  and  (in  rare  cases) 
delusions,  hallucinations,  threats  or  acts  of  violence,  outbursts  of 
excitement  or  attacks  of  acute  mania,  may  be  mentioned. 

Amongst  the  latter  {negative  symptoms,  or  those  which  are  as- 
sociated with  diminution  or  abolition  of  function,  and  in  which  the 
primary  lesion  is  usually,  at  all  events,  a  "  destroying "  one),  the 
following  are  some  of  the  more  important : — more  or  less  intellectual 
impairment,  loss  of  memory,  want  of  attention,  loss  of  the  power  of 


Fig,  34. — Transverse  vertical  section  through  the  left  and  portions  of 
the  right  hemisphere  of  the  brain,  at  the  level  of  the  greatest  convexity  of 
the  pons  Varolii,  in  case  of  diffused  melanotic  sarcoma,  showing  an  enor- 
mous number  of  melanotic  deposits  in  the  grey  matter  of  the  cerebrum  and 
in  the  substance  of  the  pons  Varolii.     (Reduced  from  a  photograph.) 

The  letter  A  points  to  a  spot  just  above  the  lateral  ventricle  on  the  left  side ; 
B  and  B,  to  melanotic  deposits  in  the  grey  matter  of  the  cerebral  cortex. 

mental  application  and  concentration,  want  of  former  mental  "s-igour 
and  liveliness,  listlessness,  taciturnity,  depression  of  spirits,  marked 
melancholia,  apathy,  lethargy,  absence  of  intellectual  interest  in 
surrounding  objects,  want  of  attention  to  calls  of  nature,  excessive 
sleepiness,  stupor, — in  short,  complete  dementia  and  coma. 

Tlie  causation  of  tlie  mental  symjitoms. — In  many  cases  the  mental 


THE  CAUSATION  OF  THE  MENTAL  SYMPTOMS,      in 

alterations  are  probably  due  to  a  widespread  derangement  of  brain 
function — in  others,  to  localised  lesions  in  special  parts. 

The  alterations  in  the  vascular  and  lymph  supply,  and  the  com- 
pression of  the  nerve  tissue,  which  attend  increased  intracranial 
pressure ;  the  fine  irritative  changes,  which  in  some  cases  are  so 
extensively  diffused  through  the  brain,  and  which  are  perhaps  the 
result  of  some  irritative  material  produced  by  the  metabolism  in  the 
tissues  of  the  tumour,  or  in  the  area  of  cerebral  softening  which 


Fig.  35. — Camera  lucida  drawing  of  a  microscopical  section  through  a 
portion  of  three  convolutions  of  the  brain  in  case  of  diffused  melanotic 
sarcoma,  showing  numerous  sarcomatous  nodules  in  the  grey  matter.  Very 
low  power.  (Hartnack,  ocular  2,  objective  1,  and  drawing  reduced  from 
8  to  4  inches. ) 

The  letters  a,  a,  a  point  to  the  cut  edges  of  the  section  ;  b,  b  to  trans- 
versely divided  vessels  in  the  membranes  on  the  surface  of  the  brain  ;  c,  c 
to  masses  of  melanotic  sarcoma  in  the  grey  matter;  d,  to  the  white  substance 
in  the  centre  of  a  convolution. 


surrounds  it,  and  the  oedema  of  the  brain  tissue  which  attends  dropsy 
of  the  ventricles,  are  obvious  causes  of  deranged  nutrition  or  of  func- 
tional disturbances  in  the  nerve  cells  of  the  cortex  and  in  the 
extremely  delicate  network  of  nerve  fibres  which  connects  different 
nerve  cells  and  groups  of  nerve  cells  together.  It  is  obvious  that 
even  slight  derangements  in  the  nutrition  of  these  structures  must 


112 


ANALYSIS  OF  INDIVIDUAL  SYMPTOMS. 


necessarily,  when  widely  spread,  be  attended  with  some  mental 
alteration,  although  the  symptoms  may  in  some  cases  be  so  shght  as 
to  be  with  difficulty  recognisable. 


/I 
I 


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'&!•  =  ,-*"  life-..**    .iJ^   4S    ' 


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■^i:-'(p-  ^ 


'      v,r.    qfi      Oamera  luciila  drawing  of  a  microscopical  section  of  a  portion 
f  thf  ^revmSTr  o     he  cort^^  of  the  brain  in  case  of  diftused  mehanotic 

of  whfcht   s^diicult'to  distinguish  under  this  xnagmfymg  power)  are 
grouped  in  a  most  remarkable  manner  around  the  l>l-d.vessel 
"     The  letter  A  points  to  the  membranes  on  the  free  surface  of  the  convom 
tion%,  to  a  portion  of  the  grey  matter  which  is  not  invaded  ,  C,  C,  to 
masses  of  pigmented  cells  surrounding  the  vessels. 


MENTAL  SYMPTOMS. 


113 


Again,  the  localised  irritation  or  destruction  which  is  the  direct 
result  of  the  pressure  of  the  tumour  on  special  parts  of  the  brain 
tissue,  or  of  the  inflammatory  and  other  changes  which  are  estab- 


,^^^ 
4P' 


Fig.  37. — Camera  lucida  drawing  of  blood-vessels  from  the  grey  matter 
of  the  brain  in  case  of  diffused  melanotic  sarcoma,  showing  vessels  and  pig- 
mented sarcomatous  cells  surrounding  them.  (High  power — Hartnack, 
oc.  3,  obj.  8,  tube  out,  and  drawing  reduced  from  6^  to  5  inches.) 

The  letter  a  points  to  a  vessel  of  some  size  at  a  point  where  the  vessel 
wall  is  unsurrounded  by  cells  ;  6,  to  a  large  mass  of  cells  surrounding  a 
vessel  ;  c  and  d,  to  small  vessels  surrounded  with  cells  ;  e,  f,  and  g,  to  pig- 
mented sarcomatous  cells  of  various  shapes,  which  are  making  their  way 
along  narrow  Ij^mphatic  spaces,  and  are  in  consequence  very  finely  drawn  out. 

H 


114 


ANALYSIS  OF  INDIVIDUAL  SYMPTOMS. 


lislied  in  the  immediate  neighbourhood  of  the  new  growth,  may  cause 
mental  symptoms,  either  by  the  direct  damage  which  they  occasion, 
or  by  the  indirect  (reflex)  effects  (irritation  and  inhibition)  which 
they  produce  in  other  and  distant  parts  of  the  brain  tissue.  In  the 
remarkable  case  of  melanotic  sarcoma  which  is  represented  in  Figs, 
33,  34,  35,  36,  37,  and  38,  the  profound  mental  disturbance  which 
was  present,  was  obviously  due  to  the  extraordinary  manner  in  which 


t-'-i 


t)l  I 


Fig,  38. — Camera  lucida  drawing  of  a  section  through  the  surface  of  a 
convolution  of  the  brain  in  case  of  diffused  melanotic  sarcoma.  (High  power 
— Hartnack,  oc.  3,  obj.  8,  tube  out,  and  dramng  reduced  from  1\  to  2 
inches. ) 

The  letter  a  points  to  the  membranes  on  the  free  surface  of  the  convolu- 
tion ;  6,  to  a  small  (capillary)  vessel  passing  into  the  grey  matter  ;  c,  to  a 
group  of  large,  rounded,  and  in  some  cases  multinucleated  sarcomatous 
■  cells  containing  jjigment. 

the   new   growth    was  diffused   throughout   the   whole  grey  matter 
of  the  cerebrum. 

Direct  damage  to  the  frontal  lobe  seems  in  some  cases  to  be 
attended  with  distinct  mental  disturbances,  the  exact  nature  of 
which  will  be  afterwards  described.  Tumours  of  the  non-motor 
regions  at  the  back  of  the  brain  are,  according  to  Dr.  Hughlings 
Jackson,   more    frequently   attended   with    mental    symptoms   than 


DERANGEMENTS  OF  SPEECH.  115 

tumours  in  the  motor  area  ;  but  whether  the  mental  symptoms, 
which  seem  to  be  associated  with  lesions  of  the  occipital  and 
other  sensory  centres,  are  due  to  direct  destruction  of  tissue  {i.e., 
of  the  nerve  centres  of  the  occipital  lobe),  or,  as  is  perhaps  more 
likely,  to  the  more  widely  distributed  indirect  effects  (irritative  or 
inhibitory)  which  a  lesion  of  a  sensory  centre  may  be  expected  to 
produce  upon  other  centres,  is  perhaps  doubtful.  Be  that,  however, 
as  it  may,  the  mental  symptoms  which  have  been  described  in  the 
foregoing  section  can  hardly  be  said,  in  the  present  position  of  our 
knowledge,  to  have  any  distinct  localising  value. 

Deeangements  of  Speech — Aphasia. 

Any  of  the  different  speech  derangements,  which  are  classed 
together  under  the  general  term  aphasia,  may  be  caused  by  an 
intracranial  tumour,  but  in  most  cases  the  speech  derangement  is 
either  temporary  (post-epileptic  aphasia)  or  incomplete ;  it  is  rare  to 
find  a  tumour  producing  the  more  complete  forms  of  permanent 
aphasia,  such  as  result  from  embolic  plugging  of  the  nutrient  vessels. 

Aphasic  symptoms,  when  they  do  occur,  are  not  only  of  great 
scientific  interest,  but  of  distinct  localising  value.  Hence,  in  all  cases 
in  which  speech  derangements  of  an  aphasic  kind  are  present,  the 
exact  form  of  the  aphasia  (whether  sensory  or  motor,  word-blindness, 
word-deafness,  aphemia,  or  agraphia)  and  the  degree  of  the  impair- 
ment must  be  carefully  investigated. 

As  we  all  know,  the  speech  derangements,  grouped  together  under 
the  common  term  aphasia,  are,  in  right-handed  persons,  almost  always 
due  to  lesions  in  the  left  hemisphere  of  the  brain ;  while  in  left- 
handed  persons  the  reverse  is  usually  the  case.  In  those  exceptional 
cases  in  which  in  a  right-handed  person  the  lesion  is  found  in  the 
right,  or  in  which  in  a  left-handed  person  it  is  found  in  the  left  hemi- 
sphere, the  patient  may  have  been  ambidextrous ;  for  the  few 
instances  in  which  this  is  not  so,  no  explanation  (unless  a  second 
lesion  has  been  overlooked)  is  at  present  forthcoming.  The  presence, 
therefore,  of  any  distinct  degree  of  aphasia  is,  in  the  case  of  a  right- 
handed  person,  strongly  suggestive  that  the  tumour  is  situated  in  the 
left  hemisphere  of    the    brain.     Further,   if  the   aphasia    is   motor 


ii6  ANALYSIS  OF  INDIVIDUAL  SYMPTOMS. 

(aphemia  or  agraphia),  the  lesion  is  probably  situated  in  or  about  the 
posterior  end  of  the  lower  or  third  frontal  convolution.  In  cases  of 
"word-deafness"  it  probably  involves  the  upper  or  first  temporo- 
sphenoidal  convolution ;  and  in  the  cases  of  "  word-blindness/'  it  is 
probably  situated  in  or  about  the  angular  gyrus  (see  Fig.  39).  But 
as  previously  pointed  out,  marked  and  permanent  aphasia,  whether 
motor  or  sensory,  is  rarely  met  with  in  cases  of  cerebral  tumour. 

It  must  also  be  remembered  that  aphasia  may  be  due  to  inter- 
rupted  conduction   through  the   fibres,  which  connect  the    sensory 

.2 


Fig  39.-OutUne  of  the  left  hemisphere  of  the  brain,  showmg  the 
position  of  the  lesion  in  different  forms  of  aphasia.     (After  Bernard.) 

1  Fissure  of  Svhdns  ;  2.  Fissure  of  Rolando  ;  3.  Interparietal  sulcus  ; 
4    Parallel  fissure  ;  5.  External  perpendicular  fissure. 

i?!    first  ;  iJ"-,  second:  and  i?%  third  frontal  convolutions         _ 

AF,  ascending  frontal ;  and  AP,  ascending  parietal  convolutions.  F, 
superior°parietal  lobule  ;  P\  inferior  parietallobule,  or  angular 
eyrus  •  P\  Pli  courbe  ;  T\  first  ;  T- ,  second  ;  and  T\  third 
temporal  convolutions.  OS  first  ;  0",  second  ;  and  0^  third 
occipital  convolutions.  _         i       •  \ 

MF,  the  position  of  the  lesion  in  motor  aphasia  (aphemia). 

A'jl  the  supposed  position  of  the  lesion  in  agraphia. 

wh,  position  of  the  lesion  in  word-deafness. 

"WB,  position  of  the  lesion  in  word-blindness. 

with  the  motor  speech  centres,  and  it  is  probable  that  this  is  the 
position  of  the  lesion  in  some  cases  of  combined  sensory  motor  aphasia. 
Further,  as  Dr.  Charlton  Bastian  has  shown,  disorders  of  the  sensory 
speech  centres  necessarily  produce  more  or  less  derangement  of  the 
motor  speech  centres,  which  act  in  conjunction  with  them.  It  is 
impossible  to  go  into  details,  and  to  attempt  to  explain  this  and  the 
many  intricate  questions  connected  with  this  most  interesting  and 


APOPLECTIC  AND  PSEUDO-APOPLECTIC  ATTACKS.  117 

difficult  subject.  Enough  has  been  said  to  show  that  the  exact 
character  of  the  aphasic  symptoms  may  give  important  information 
as  to  the  position  of  the  tumour. 

Ajjoplectic  and  pseudo-apoplectic  attadcs. 

Sudden  losses  of  consciousness  are  not  uncommon  in  the  course 
of  intracranial  tumours,  more  especially  when  the  new  growth  is  a 
glioma  or  a  syphiloma. 

In  some  cases  the  attack  is  due  to  htumorrliagic  extravasation  in  or 
about  the  tumour.  In  these  cases,  in  which  the  tumour  is  very  often 
a  highly  vascular  glioma  (see  Figs.  40,  41,  and  42),  the  behaviour  of 


Fig.  40. — Extreme  dilatation  of  the 
blood-vessels  in  a  case  of  glioma.  Seve- 
ral aneurismal  dilatations  are  seen. 

The  letter  A  points  to  a  portion  of  a 
vessel  seen  in  transverse  section  ;  its 
coats  are  very  much  thickened. 


^ri'^ 


Fig.  41. — Section  through  a  portion  of 
a  gliomatous  tumour,  showing  a  varicose  and 
aneurismally  dilated  vessel  surrounded  \vith 
ffhol  ceUs. 


the  temperature  during  the  stage  of  coma,  and  the  whole  progress  of  the 
case,  may  exactly  resemble  an  attack  of  ordinary  cerebral  haemorrhage. 
If  the  patient  should  die  during  the  stage  of  coma,  the  true 
significance  of  the  post-mortem  appearances  may  under  such  circum- 
stances be  easily  overlooked,  and  the  fact  that  the  primary  and 
real  lesion  is  a  new  growth  (glioma  or  other  vascular  tumour)  may 
not  be  recognised.  Eepeated  small  h£emorrhages,  each  attended  with 
coma,  of  longer  or  shorter  duration,  sometimes  occur.     In  the  Edin- 


I J  8  ANAL  YSIS  OF  INDI VI D  UA L  S  YAIPTOMS. 

hurgh  Medical  Journcd  for  January  1887,  I  have  reported  a  typical 
case  of  this  kind,  in  which  the  remains  of  several  small,  old  haemor- 
rhages were  found  post  mortem. 


Fig.  42. — Camera  lucida  drawing  of  a  microscopical  section  in  a  case  of 
glioma,  showing  aneurismal  dilatation  of  the  minute  vessels.  (Stained  with 
picro-carmine,  cleared  with  absolute  alcohol  and  oil  of  cloves,  and  mounted 
in  xylol  balsam.)  Magnified — Hartnack,  oc.  3,  obj.  8,  and  drawing  reduced 
from  8  to  4  inches. 

The  letter  A  points  to  a  transversely  divided  vessel  ;  i?,  to  a  vessel  vnth. 
numerous  aneurismal  dilatations  ;  C,  to  a  large  aneurismal  dilatation.  The 
tissue  of  the  tumour,  in  the  midst  of  which  the  vessels  lie,  and  many  of  the 
vessels  themselves,  have  been  omitted  from  the  drawing. 

In  other  cases,  iu  which  there  is  no  lumnorrhagic  extravasation, 
congestion,  cedema,  obstruction  of  vessels,  rapid  increase  of  ventricular 
dropsy,  and  an  epileptic  fit,  are  possible  causes  of  the  coma.     Pseudo- 


STATE  OF  NUTRITION.  119 

apoplectic   attacks,   as  they  are   technically   termed,    are   especially 
common  in  cases  of  cerebral  syphilis. 


State  of  ISTutrition — Temperature — Pulse. 

The  general  state  of  nutrition  is  often  remarkably  well  preserved  in 
cases  of  intracranial  tumour ;  even  in  cases  of  scrofulous  tumour  the 
general  condition  may,  for  a  time  at  all  events,  be  little  impaired. 

In  those  cases  in  which  pain,  sleeplessness,  and  vomiting  are 
prominent  symptoms,  the  general  health  may  fail,  and  emaciation 
rapidly  take  place  even  in  the  earlier  stages  of  the  case.  In  most 
cases  in  which  nutrition  fails  early  the  condition  is  due  to  the  presence 
of  associated  lesions  in  the  abdominal  or  thoracic  viscera.  Towards 
the  end  of  long-continued  cases  emaciation  is  often  extreme.  In 
cases  of  tumour  of  the  pituitary  body,  the  patient  often  becomes 
abnormally  fat ;  whether  this  is  due  to  the  lesion  of  the  pituitary 
body  itself,  or  to  the  secondary  alterations  which  a  tumour  in  this 
situation  is  apt  to  produce  in  the  surrounding  nervous  structures,  is 
not  as  yet  determined. 

In  some  cases  of  intracranial  tumour  tlu  appetite  is  voracious  ;  and 
it  is  perhaps  owing  to  this  fact  that  the  body  weight  is  sometimes  so 
well  preserved.  Drs.  Lawson  and  Bevan  Lewis,  who,  so  far  as  I  know, 
were  the  first  to  direct  prominent  attention  to  this  subject,  thought 
that  the  voracious  appetite  was  an  early  symptom  in  cases  of  intra- 
cranial tumour.  Though  I  have  personally  met  with  a  voracious  appetite 
in  the  early  stages  of  intracranial  tumour,  I  am  disposed  to  think  that 
it  is  much  more  frequently  a  late  symptom  ;  and  that  it  is  usually  a 
result  of  the  general  mental  deterioration  which  is  so  often  present. 

The  temperature  is  almost  always  normal  or  subnormal  in  uncom- 
plicated cases  of  intracranial  tumour.  Elevation  of  temperature 
usually  indicates  the  occurrence  of  inflammatory  complications  in  the 
membranes  (meningitis),  but  it  may  be  due  to  cerebritis.  IMills  and 
Lloyd  conclude,  as  the  result  of  their  observations,  that  in  brain 
tumours  the  average  temperature  of  the  whole  head  is  elevated 
several  degrees  above  the  normal,  and  that  the  elevation  of  tempera- 
ture is  usually  greatest  at  the  station  nearest  the  new  growth.  ^     I 

^  Teinper's  System  of  Medicine,  vol.  v.,  p.  1037. 


1 2  o  ANAL  YSIS  OF  INDIVID  UA  L  S  YMPTOMS. 

have  no  observations  of  my  own  to  offer  on  this  point,  but  it  is 
obviously  one  wliich  demands  careful  investigation.  Whether,  too, 
tumours  in  special  parts  of  the  brain  produce  modifications  in  the 
body  heat  (elevations  or  depressions) — whether,  in  short,  there  are 
cortial  heat  centres  or  not,  and,  if  so,  what  is  the  exact  position — is 
still  undetermined.  On  theoretical  grounds  we  might  perhaps  expect 
lesions  (tumours)  in  the  pons  Varolii  or  medulla  oblongata  to  be 
attended  with  more  marked  temperature  alterations  than  tumours  in 
other  parts  of  the  brain  tissue ;  but  the  theoretical  questions,  which  I 
have  discussed  elsewhere,^  need  not  be  debated  here.  Lesions  in  the 
pons  Varolii  do,  however,  appear  in  some  instances  to  be  attended 
with  hyperpyrexia. 

In  exceptional  cases  of  intracranial  tumour,  the  onset  of  the  attack 
is  attended  with  febrile  disturbances, — probably  due  in  most  cases  to 
meningitis,  and  in  some  perhaps  to  tubercular  meningitis.  In  the 
later  stages,  rises  of  temperature  due  to  tliis  cause  are  more  common. 

W]ien  ha?morrhagic  extravasations  occur  from  the  vessels  of  a 
tumour,  the  same  alterations  in  the  temperature  curve  may  be  noted 
as  in  cases  of  ordinary  cerebral  haemorrhage  (ordinary  h£emorrhagic 
apoplexy). 

The  exact  observation  of  the  temperature  is  probably  of  con- 
siderable importance  in  distinguishing  the  pseudo-apoplectic  seizures, 
which  occur  in  the  course  of  some  cases  of  cerebral  tumour,  more 
especially  in  cases  of  cerebral  syphilis,  from  the  apoplectic  attacks 
associated  with  hcemorrhagic  extravasation.  In  pseudo- apoplectic 
attacks,  the  initial  depression  which  attends  the  onset  of  a  copious 
cerebral  haemorrhage  is  not  observed. 

In  those  cases  of  intracranial  tumour  in  which  the  temperature  is 
elevated,  the  observer  must  of  course  be  on  his  guard  to  exclude  all 
other  sources  of  pyrexia  (such  as  inflammatory  complications  in  the 
thorax  or  abdomen)  before  coming  to  the  conclusion  that  the  eleva- 
tion of  temperature  is  due  to  the  intracranial  lesion  (meningitis, 
cerebritis,  &c.). 

The,  ]pulsc  frequency  is,  as  a  rule,  either  normal  or  diminished  in 
the  earlier  stages  of  intracranial  tumours ;  towards  the  end  it  may 
become  increased. 

^   Practical  Medicine  aiul  Medical  Diayncsis,  p.  68. 


URINAR  Y  AL  TERA  TIONS.  1 2 1 

Diminished  pulse  frequency  is  often  associated  with  increased 
intracranial  pressure.  In  some  cases  it  is  perhaps  the  direct  result 
of  irritation  of  the  vagi  nerves,  or  their  nuclei  in  the  medulla  oblongata. 

Exacerbations  of  the  headache  may  be  accompanied  by  diminu- 
tion in  the  frequency  of  the  pulse. 

Vaso-motor  flushings  are  occasionally  present ;  and  in  one  case  of 
melanotic  sarcoma,  which  has  been  already  referred  to,  they  were 
very  striking  phenomena.  In  that  case  the  vaso-motor  disturbances 
were  accompanied  with  severe  headache,  flashes  of  bright  light  in  the 
eyes,  blindness,  and  alterations  in  the  frequency  of  the  pulse.  ^ 

Alterations  in  the  urinary  secretion  (other  than  those  depending 
upon  the  disturbances  of  the  urinary  reflex,  which  have  been  pre- 
viously referred  to)  are  occasionally  observed. 

The  presence  of  an  excess  of  'plios'phates  is  very  common,  but  of  no 
localising  significance. 

Polyuria,  glycosuria,  and  occasionally  albuminuria,  have  been 
noted,  more  especially  in  those  cases  in  which  the  tumour  involved 
the  pons  Varolii  or  medulla  oblongata.  Tumours  of  the  pituitary 
body  seem,  in  some  instances  at  all  events,  to  be  attended  with  poly- 
uria and  glycosuria. 

Bed  sores  are  often,  of  course,  present  in  the  later  stages  of  intra- 
cranial tumours.  Derangements  of  respiration  may  be  the  direct 
result  of  the  intracranial  lesion,  more  especially  when  it  is  sub- 
tentorial  and  involves  the  medulla  oblongata,  but  are  usually  due  to 
some  associated  lesion  within  the  thorax.  Ghcyne-Stokes  respiration 
is  not  uncommon  before  death. 

^  See  Edinburyh  Medical  Journal,  July  1887. 


CHAPTER   VII. 

DIAGNOSIS  AND  DIFFEEENTIAL  DIAGNOSIS. 

Diagnosis. 

The   diagnosis  of   intracranial  tumours   is   in   some  cases  easy ;   in 
others  most  difficult ;  in  others,  again,  impossible. 

As  Dr.  Hufrhlincjs  Jackson — to  whom  we  are  indebted  for  so  much 
of  our  knowledge  on  the  whole  subject  of  intracranial  tumours — long 
ago  pointed  out,  three  questions  present  themselves  for  solution,  viz. : 

1.  Is  there  an  intracranial  tumour  ? 

2.  If  so,  where  is  it  situated  ? 

3.  What  is  its  pathological  nature  ? 

Step  No.  1. — Is  there  an  intracranial  tumour  ? 

In  the  first  of  the  clinical  groups  into  which  I  have  divided  cases 
of  intracranial  tumour  a  diagnosis  is  obviously  impossible. 

In  the  second,  it  is  generally  possible  to  come  to  a  positive  opinion 
without  much  difficulty ;  but  it  is  necessary  to  exclude  certain  con- 
ditions, such  as  Bright's  disease  and  lead  poisoning,  in  which  head- 
ache, vomiting,  double  optic  neuritis,  and  the  other  "  general " 
symptoms  of  intracranial  tumour  may  be  present. 

In  the  tJm'd,  the  diagnosis  is  still  more  easily  and  certainly 
arrived  at ;  for  the  presence  of  symptoms  indicative  of  a  local  cerebral 
lesion  confirms  very  strongly  the  diagnosis  of  intracranial  tumour 
suggested  by  the  general  symptoms. 

The  cases  comprised  in  the  fourth  clinical  group  present  the 
greatest  difficulties  in  diagnosis. 

(a.)  The  uncertainty  and  difficulty  are  in  some  cases  due  to  the  fact 
that  some  symptom  or  symptoms  which  one  would  expect  to  be 
present  in  a  typical  case  of  intracranial  tumour  are  altogether  absent 
or  only  slightly  marked.  Now  double  optic  neuritis  is,  as  we  have 
seen,  the  most  important  of  all  the  symptoms  of  intracranial  tumour ; 
and  it  is  in  the  absence  of  double  optic  neuritis  that  doubt  is  chiefly 


DIAGNOSIS.  123 

ajDt  to  arise.  Such  conditions  as  migraine,  hysteria,  hypermetropia, 
and  anaemia  with  or  without  hypermetropia,  in  which  many  of  the 
general  symptoms  of  an  intracranial  tumour  may  be  present,  are 
those  which  most  frequently  give  rise  to  difficulty. 

(&.)  In  other  cases  the  symptoms  are  clearly  indicative  of  a  local 
cerebral  lesion,  but  the  general  symptoms  are  not  characteristic  of  a 
tumour. 

Kepeated  attacks  of  Jacksonian  epilepsy — (1)  without  headache, 
vomiting,  and  double  optic  neuritis ;  or  (2)  with  slight  headache,  and 
without  vomiting  and  optic  neuritis — may  be  mentioned  in  illustra- 
tion. The  lesion  in  such  cases  may  be  a  tumour,  but  without  cutting 
down  upon  it  and  actually  seeing  the  condition  of  the  parts,  a  positive 
diagnosis  under  such  circumstances  is  not  possible,  for  the  same 
symptoms  may  be  due  to  a  localised  softening  or  cerebritis. 

(c.)  In  others,  again,  the  symptoms  are  suggestive  of  meningitis ; 
in  fact,  in  some  cases  the  differential  diagnosis  of  intracranial  tumour 
and  meningitis  is  very  difficult. 

Let  us  now  consider  seriatim  the  differential  diagnosis  of  intra- 
cranial tumour,  and  of  the  various  conditions  with  which  it  is  likely 
to  be  confounded. 

The  Differential  Diagnosis  of  Intracranial  Tumour  and  BrigMs 

Disease. 

In  those  cases  of  Bright's  disease  in  which  there  is  little  or  no 
dropsy,  headache  and  vomiting  are  often  marked  and  distressinf^ 
symptoms,  the  headache  being  in  many  instances  confined  to  the 
back  of  the  head.  Now,  in  many  cases  of  this  description — and  they 
are  chiefly  cases  of  chronic  cirrhotic  Bright — dinmess  of  vision  is  a 
prominent  symptom,  and  there  are  marke'd  ophthalmoscopic  appear- 
ances which  it  is  not  always  easy,  and  which  in  some  cases  it  is  im- 
possible, to  distinguish  from  the  ophthalmoscopic  changes  produced 
by  intracranial  tumours.  In  both  conditions  there  may  be  epilepti- 
form convulsions,  or  even  genuine  apoplectic  seizures ;  and  in  both 
hemiplegia—  a  localising  symptom,  it  will  be  noticed—  may  be  present. 
Obviously,  therefore,  the  two  conditions  may  be  easily  mistaken  the 
one  for  the  other.  The  chief  points  to  which  attention  should  be 
directed  in  making  the  differential  diagnosis  are  as  follows  : — 


124  DIFFERENTIAL  DIAGNOSIS. 

1.  The,  condition  of  the  urine. — The  examination  of  the  urine  will 
generally  clear  up  all  difficulty  and  doubt ;  for  in  the  majority  of 
cases  of  chronic  Briglit's  disease,  which  simulate  intracranial  tumour, 
distmct  alterations  indicative  of  the  renal  lesion — such  as  the  presence 
of  albumen  and  tuloe  casts — are  present  in  the  urine. 

It  must,  however,  be  remembered  that  in  some  cases  of  cirrhotic 
Bright — the  form  which  is  most  likely  to  simulate  intracranial  tumour 
— albumen  is  scanty  or  even  altogether  absent ;  and  that  tube  casts 
may  be  so  few  and  far  between  as  easily  to  escape  detection.  In 
cases  of  this  description  the  amount  of  urine  is  considerably  increased, 
and  the  specific  gravity  markedly  below  the  normal. 

2.  The,  condition  of  the  heart,  arteries,  and  Uood.  irressare. — In  all 
forms  of  Bright's  disease  (except,  in  my  opinion,  pure  and  uncomplicated 
cases  of  waxy  disease)  the  blood  pressure  is  high,  tbe  arteries  are  apt 
to  become  atheromatous,  and  the  left  ventricle  hypertrophied.  These 
cardiac  and  vascular  alterations  are,  however,  much  more  marked  in 
the  cirrhotic  form  ;  indeed,  in  many  cases,  the  degree  of  blood  pressure 

and  the  amount  of  cardiac  hypertrophy  seem 
to  be  directly  proportionate  to  the  extent  of 
the  cirrhosis. 

Obviously,  therefore,  the  careful  examina- 
FiG.  43.— Sphygmographic     tiou  of  the  heart  and  arteries  is  a  point  of 
tracing.    High  tension.       ^^^^^  diagnostic  importance.     A  large  hyper- 

trojihied  left  ventricle,  without  valvular  disease  to  account  for  it,  a 
hard  pulse  and  characteristic  sphygmographic  tracing  (see  Fig.  43),  or 
an  atheromatous  condition  of  the  arterial  walls,  are  strongly  suggestive 
of  chronic  kidney  disease,  more  especially  cirrhosis. 

3.  The  exact  character  of  the  ophtha.linoscopic  chaivjcs. — In  the  great 
majority  of  cases  of  intracranial  tumour,  the  retinal  change  is  a 
papillitis,  of  greater  or  less  severity ;  and  in  the  great  majority  of 
cases  of  renal  disease  the  changes  in  the  fundus  oculi  are  those  de- 
scribed under  the  term  albuminuric  retinitis  (see  Fig.  44).  But  in 
some  cases  of  tumour  the  retinal  changes  resemble,  more  or  less 
closely,  those  of  Bright's  disease,  white  spots  or  streaks  being  present 
in  the  neighbourhood  of  the  macula ;  and  vice  versa,  in  some  cases  of 
Bright's  disease,  the  white  patches  are  absent  and  the  retinal  change 
is  essentially  a  papillitis. 


INTRACRANIAL  TUMOUR  AND  B RIGHTS  DISEASE.  125 

Again,  the  appearance  in  the  fundus  (both  in  tumour  and  Bright's 
disease)  may  be  suggestive  of  either,  but  characteristic  of  neither 
affection. 

To  sum  up,  in  most  cases  it  is  easy  to  decide,  by  means  of  the 
ophthahnoscope,  whether  the  retinal  changes  are  characteristic  of 
cerebral  tumour  or  of  kidney   disease;   but   in  some  cases  tliis  is 


Fig.  44. — Fundus  oculi  in  a  case  of  albuminuric  retinitis.  Numerous 
white  patches  are  seen  in  the  retina,  more  especially  in  the  neighbourhood 
of  the  macula. 

difficult  or  impossible.  The  ophthalmoscopic  appearances,  inr  se,  can 
never  be  taken  as  an  absolutely  certain  guide,  for  the  appearances 
typical  of  one  condition  are,  in  some  rare  and  exceptional  cases,  met 
with  in  the  other. 

In  reference  to  this  point.  Dr.  Gowers  says — "Although  the  re- 
semblance in  the  appearance  of  the  fundus  in  the  two  cases  is  some- 
times close,  it  is  rarely  that  the  diagnosis  cannot  be  made  by  a  careful 
examination.  The  white  spots  about  the  macula  are  the  result  of 
damage  produced  during  the  acute  stage  of  the  neuritis,  when  it 
involves  the  adjacent  retina  ;  and,  as  an  almost  invariable  rule,  when 


126  DIFFERENTIAL  DIAGNOSIS. 

they  are  seen  as  scattered  spots  resembling  those  of  Bright's  disease, 
the  inflammation  of  the  papilla  is  distinctly  subsiding  and  the  swell- 
ing has  become  pale,  although  its  characters  (constriction  of  vessels, 
&c.)  indicate  that  the  previous  inflammation  was  great  in  degree.  On 
the  other  hand,  in  most  cases  of  Bridit's  disease  in  which  the  scattered 
white  spots  appear,  the  papilla  is  but  little  affected  by  inflammation, 
and  that  usually  show^s  no  signs  of  subsidence.  Considerable  difficulty 
only  exists  in  the  cases  just  spoken  of,  in  which  the  nephritic  retinal 
changes  are  accompanied  by  a  preponderating  neuritis,  which  runs  its 
course  and  then  subsides.  During  the  stage  of  subsidence  the  appear- 
ance of  the  fundus  may  be  exactly  similar  to  that  in  some  cases  of 
cerebral  disease  or  of  primary  papillitis."  ^ 

4.  The  character  of  the  headache. — In  Bright's  disease  the  headache 
is  not  as  a  rule  so  severe  and  unbearable  as  it  is  in  many  cases  of 
tumour.  Very  severe  and  distressing  headache  is  therefore  sug- 
gestive of  tumour.  The  contrary  proposition  (that  mild  headache  is 
suggestive  of  Bright's  disease)  does  not,  however,  hold  good ;  for  in 
some  cases  of  timaour  the  headache  is,  as  we  have  seen,  slight. 

In  many  cases  of  Bright's  disease  the  headache  is  chiefly  occipital ; 
but  this  fact  is  of  little  value  for  diagnostic  purposes,  for  in  some  cases 
of  tumour  (more  especially  when  the  new  growth  is  situated  beneath 
the  tentorium)  the  same  localisation  of  the  headache  is  observed. 

5.  The  age  of  the  patient. — This  may  be  of  some  importance,  for 
cirrhotic  Bright's  disease  (the  form  most  likely  to  be  confounded  with 
tumour)  rarely  affects  young  people.  The  fact  that  the  patient  is 
young  (under  twenty  years)  is  therefore  in  favour  of  tumour.  Abso- 
lute reliance  cannot,  however,  be  placed  on  this,  nor  indeed  upon  any 
other  single  fact  or  symptom. 

The  important  lesson  to  be  drawn  from  the  foregoing  statements 
(which  show  the  close  resemblance  that  there  sometimes  is  between  the 
symptoms  produced  by  an  intracranial  tumour  and  Bright's  disease) 
is  never  to  commit  oneself  to  a  definite  diagnosis  of  intracranial 
tumour,  without  having  previously  examined  the  urine  and  excluded 
Bright's  disease. 

It  must  also  be  remembered  that  in  rare  cases  the  two  diseases 
(Bright's  disease  and  intracranial  tumour)  are  combined.     Hence  the 

^   Transactions  of  the  Oplitliahnological  Society  of  the  United  Kingdom,  vol.  i.,  p.  103. 


LEAD  ENCEPHALOPATHY.  127 

fact  that  there  is  Bright's  disease  (as  shown  by  the  condition  of  the 
urine,  &c.)  does  not  absolutely  prove  that  there  is  no  tumour.  The 
numerical  chances  are  strongly  against  such  a  combination,  and  in 
the  great  majority  of  cases  it  would  be  quite  safe,  having  detected 
kidney  disease,  to  stop  there  and  to  exclude  tumour.  In  a  few  cases 
such  a  method  of  diagnosis  would  lead  to  error,  and  the  j)]iysician 
should  always  ask  himself  (having  detected  Bright's  disease),  whether 
the  kidney  lesion  is  sufficient  to  account  for  the  cerebral  symptoms. 

Dr.  Hughlings  Jackson  says,  with  reference  to  this  point — "  I 
have  seen  double  optic  neuritis  in  a  man  who  had  unilaterally  and 
deliberately  beginning  convulsive  seizures — a  condition  pointing 
mostly,  in  such  association,  to  cortical  tumour — and  Bright's  disease 
too.  I  saw  a  case,  many  years  ago,  under  the  care  of  Dr.  Habershon, 
in  which  there  were  found,  post  mortem,  both  renal  disease  and 
intracranial  tumour,  although  in  this  case  intracranial  disease  was 
diagnosed  from  other  nervous  symptoms."  ^ 

Tlu  Differential   Diagnosis   of  Intracranial   Tumour  and   Lead 
Encephalopathy. 

In  the  slighter  forms  of  lead  poisoning,  such  as  are  usually  met 
with  in  private  practice,  head  sjmiptoms  are  rarely  observed  ;  but 
when  large  quantities  of  lead  are  introduced  into  the  system,  very 
grave  symptoms,  which  in  some  cases  closely  resemble  those  produced 
by  intracranial  tumours,  may  arise.  Cases  of  this  kind  not 
infrequently  prove  fatal. 

Persons  employed  in  the  manufacture  of  white  lead  often  suffer  in 
this  way  ;  and  in  Newcastle  such  cases  used  frequently  to  come 
under  my  notice. 

The  symptoms  characteristic  of  lead  encephalopathy  may  com- 
mence gradually,  or  with  more  or  less  suddenness.  They  usually 
consist  of  severe  headache,  vomiting,  and  convulsions,  the  spasms 
being  in  some  cases  epileptiform,  in  others  of  the  hystero-epileptic 
type.  On  ophthalmoscopic  examination  intense  double  optic  neuritis 
is  usually,  but  not  invariably  present.  In  Brain,  January  1888, 
page  507,  I  have  recorded  a  case  of  lead  poisoning  in  which  marked 

*   Transactions  of  the  Opiitliahnological  Society  of  the  United  Kingdom,  vul.  i.,  p.  62. 


128  DIFFERENTIAL  DIAGNOSIS. 

head  symptoms  and  amaurosis  were  present,  but  in  which  the  discs 
were  absolutely  healthy.  The  pupils  are  usually  dilated,  sluggish,  or 
absolutely  insensible  in  their  reaction  to  light.  In  some  cases  there 
is  strabismus ;  in  the  few  cases  in  which  I  have  observed  this  symp- 
tom it  was  double  and  internal.  During  the  acute  stage  there  is 
frequently  a  condition  of  mental  aberration  and  excitement,  in  wliich 
the  patient  may  be  so  violent  as  to  require  restraint.  This  condition 
may  last  for  some  weeks.  In  other  cases — and  these  are  usually  the 
most  severe,  and  not  infrequently  fatal — coma,  rather  than  maniacal 
excitement,  alternates  with  the  convulsions.  In  fatal  cases  the 
patient  may  be  profoundly  comatose  for  many  hours  before  death. 

The  s}Tnptoms,  more  especially  after  the  acute  stage  has  passed 
off,  may  closely  resemble  those  due  to  an  intracranial  tumour ;  and 
in  those  cases  in  wliich  no  pre^dous  history  is  forthcoming,  the 
difficulties  of  diagnosis  to  the  great  mass  of  medical  men,  who  have 
had  no  opportunity  of  seeing  cases  of  lead  encephalopathy,  may  be 
considerable.  So  closely  do  the  two  conditions  (tumour  and  lead 
encephalopathy)  in  some  cases  resemble  one  another,  that  I  never 
commit  myself  to  a  positive  diagnosis  of  intracranial  tumour  without 
having  'p^^'^iously  excluded  lead  poisoning. 

The  differential  diagnosis  is  easily  enough  made,  if  one  is  on  one's 
guard,  by  attention  to  the  following  points. 

1.  Tlie  presence  of  a  blue  line  on  the  gums,  and  other  symptoms  of 
lead  poisoning,  such  as  anmmia,  colic,  constipatio7i,  wrist  drop.  The 
characteristic  blue  line  on  the  gums  is  almost  always  present.  It 
may  be  absent  if  the  patient  has  no  teeth,  or  if  the  teeth  are  kept 
scrupulously  clean,  for  it  is  due  to  the  action  of  sulphuretted  hydrogen 
(produced  by  the  decomposition  of  food  and  other  matters  lodging 
around  the  roots  of  the  teeth)  on  the  lead,  which  is  circulating  through 
the  tissues.  The  class  of  people  employed  in  the  more  dangerous 
parts  of  the  process  of  manufacturing  white  lead  are,  in  my  experi- 
ence, essentially  dirty  ;  they  are,  too,  usually  young  women,  and 
therefore  have  teeth.  Hence  the  blue  line  is  almost  always  well 
marked.  In  one  of  my  cases,  although  the  patient  had  not  been 
exposed  to  the  poison  for  fourteen  months,  the  blue  line  was  still 
quite  perceptible.  Dr.  Eichardson  (quoted  by  Hamilton  in  his  work 
on   the  diseases  of  the  nervous  system,  page   472)  states    that   in 


LEAD  ENCEPHALOPATHY.  129 

America  the  men  suffer  more  frequently  from  lead  encephalopathy 
than  the  women. 

Since  writing  the  above  I  have  met  with  a  case  of  lead  encephalo- 
pathy in  which  the  blue  line  was  practically  absent :  in  it  there  was 
only  one  small  patch  of  blue  deposit  in  a  spongy  and  unhealthy 
portion  of  the  gum.  The  patient,  who  knew  the  risk  he  ran  of  lead 
poisoning,  had  been  scrupulously  careful  to  keep  his  teeth  clean,  and 
to  brush  them  regularly  on  returning  from  work. 

2.  Tlu  'previous  history. — In  most  cases  of  lead  encephalopathy 
the  patient  has,  prior  to  the  commencement  of  the  present  illness, 
suffered  from  the  ordinary  well-known  symptoms  of  lead  poisoning, 
such  as  colic,  wrist  drop,  lead  rheumatism,  &c. 

3.  The  occupation  of  the  p)Citient  is  a  point  of  importance,  for,  as  far 
as  I  know,  the  severe  cerebral  symptoms  to  which  the  term  lead 
encephalopathy  is  given  do  not  occur  in  plumbers,  painters,  and 
others  who  so  commonly  suffer  from  the  milder  manifestation  of  lead 
poisoning,  but,  in  this  country  at  all  events,  are  usually  confined  to 
persons  employed  in  the  manufacture  of  lead  compounds. 

4.  The  character  of  the  convulsions  and  the  peculiar  mental  condi- 
tion, which  have  been  described  above,  are  also  strongly  suggestive  of 
lead  poisoning  rather  than  of  cerebral  tumour. 

It  would  be  out  of  place  to  discuss  here  the  nature  of  the  patho- 
logical changes  which  are  the  cause  of  lead  encephalopathy.  Suffice  it 
to  say  that  in  some  cases  the  symptoms  are  due  to  the  action  of  the 
poison  upon  the  nervous  tissues  themselves  (brain,  optic  nerve,  &c.) ; 
in  others  kidney  disease  and  resulting  ursemia  seem  to  play  an  impor- 
tant part  in  their  production.  It  is  probable  that  in  many  cases  the 
cerebral  symptoms  are  due  to  a  combination  of  these  lesions.  In  all 
cases  of  suspected  lead  encephalopathy  the  urine  should  be  carefully 
examined,  and  the  exact  condition  of  the  kidneys  determined. 

5.  The  presence  of  lead  in  the  urine. — On  chemical  examination 
lead  can  probably  be  detected  in  most  cases  in  the  urine.  In  the  case 
of  lead  amaurosis  without  neuritis,  which  has  been  previously  referred 
to,  Dr.  Stevenson  Macadam,  who  kindly  examined  one  specimen  for 
me,  failed  to  detect  the  presence  of  lead  in  the  urine. 


I30  DIFFERENTIAL  DIAGNOSIS. 

The,  Differential  Diagnosis  of  Hypermetropia,  with  or  without  Ancemia, 
and  of  Intracranial  Tumour. 

Young  persons  affected  with  errors  of  refraction  not  infrequently 
suffer  from  distressing  headache  ;  and  Mr.  Cowper  states  that  the 
prolonged  use  of  the  eyes  in  some  cases  of  hypermetropia  actually 
induces  oedema  and  swelling  of  the  disc,  which  is  occasionally 
mistaken  for,  and  treated  as,  slight  optic  neuritis  depending  upon 
cerebral  disease. 

Dr.  Gowers  has  recorded  several  cases  of  optic  neuritis  in  girls 
suffering  from  chlorosis  and  hypermetropia,  in  which  the  anremia 
seemed  to  be  the  most  effective  cause  of  the  optic  neuritis,  for  under 
the  administration  of  iron  the  sight  became  normal,  although  the 
eyes  were  used  and  the  hypermetropia  was  uncorrected. 

It  would  appear,  therefore,  that  both  ansemia  and  hypermetropia 
are  in  some  cases  the  cause  of  optic  neuritis,  and  that  the  tendency 
to  inflammation  of  the  optic  papilla  is  intensified  when  both  causes 
exist  in  combination. 

In  cases  of  this  description  the  differential  diagnosis  is,  as  a  rule, 
easily  made. 

The  headache  is  not  usually  so  severe  as  it  is  in  weU-marked 
cases  of  intracranial  tumour ;  it  is  chiefly  orbital  or  frontal ;  is 
increased  by  using  the  eyes,  more  especially  by  all  efforts  which 
require  active  accommodation. 

The  fact  that  there  is  an  error  of  refraction  ;  that  on  correction  of 
that  error  by  suitable  glasses,  or  by  disuse  of  the  eyes,  the  headache 
is  relieved  ;  the  circumstance  that  Ught  hurts  the  eyes  and  aggravates 
the  symptoms ;  the  slight  degree  of  the  optic  neuritis,  and  its  sub- 
sidence under  treatment ;  together  with  the  absence  of  any  localising 
symptoms,  are  usually  sufficient  to  clear  up  all  doubts  as  to  the 
nature  of  the  case. 

There  are,  however,  some  cases  of  anaemia,  in  which  the  symptoms 
of  intracranial  tumour  are  so  closely  simulated,  that  a  differential 
diagnosis  is  very  difficult  or  altogether  impossible.  The  most  striking 
cases  of  this  kind  with  which  I  am  acquainted  were  related  by  Dr. 
Broadbent  at  the  great  debate  on  the  causation  of  double  optic  neuritis 
which  took  place  at  the  Ophthalmological  Society  a  few  years  ago. 


INTRACRANIAL  TUMOUR  AND  HYPERMETROPIA.   131 

Dr.  Broadbent  stated  on  that  occasion  "  that  he  had  recently  had 
under  his  care  at  St.  Mary's  Hospital  a  young  girl  who  for  two  years 
had  had  the  usual  symptoms  of  cerebral  tumour — very  severe  pain  in 
the  head,  vomiting,  and  double  optic  neuritis.  She  was  quite  blind 
from  atrophy  of  the  discs,  evidently  consecutive  upon  neuritis  ;  she 
still  had,  when  admitted,  violent  paroxysmal  headache  and  vomiting, 
and  passed  her  urine  and  fseces  in  bed,  not  from  unconsciousness  but 
from  indifference.  It  was  ascertained  that  the  symptoms  set  in 
immediately  after  sudden  suppression  of  the  catamenia,  and  that  she 
had  never  menstruated  during  the  two  years  of  her  illness.  The 
treatment,  therefore,  was  directed  to  the  restoration  of  this  function, 
and  the  flux  soon  appeared.  From  this  time  the  headaches  ceased ; 
she  became  cleanly,  and,  except  for  the  blindness,  was  well." 

In  another  case,  in  which  headache,  vomiting,  and  double  optic 
neuritis  had  been  coincident  with  sudden  arrest  of  the  menses,  there 
had  been  a  fatal  termination  after  many  fluctuations,  and  he  had  had 
the  opportunity  of  making  a  post-mortem  examination.  There  was 
no  tumour  nor  meningitis,  and  the  only  morbid  appearance  in  the 
brain  was  effusion  into  the  ventricles.^ 

The  Differential  Diagnosis  of  Atrophy  of  the  Brain  and  Intra- 
cranial Tumour. 

In  some  very  rare  and  quite  exceptional  cases,  in  which  the 
characteristic  symptoms  of  an  intracranial  tumour  (headache,  vomit- 
ing, and  double  optic  neuritis)  were  present  during  life,  no  coarse 
lesion  of  the  brain,  but  only  sclerosis,  atrophy,  or  microscopical  lesions, 
have  been  found  at  the  post  mortem. 

In  such  cases  a  correct  diagnosis  is  obviously  impossible. 

These  cases  show  that  the  general  symptoms  of  intracranial 
tumour  are  not  in  all  cases  sufficient  for  a  correct  diagnosis.  Unless 
localising  symptoms  are  at  the  same  time  present,  the  most  experi- 
enced observers  will  occasionally,  in  the  present  state  of  our  know- 
ledge, make  mistakes,  and  fail  to  find  on  post-mortem  examination 
the  tumour  which  had  been  confidently  expected  during  life.  It 
remains  to  be  seen  whether  more  extended  observation  and  experience 
will  enable  a  distinction  to  be  made  in  cases  of  this  description. 

^  Transactions  of  the  Ophthalmological  Society  of  the  United  Kingdom,  vol.  i.,  p.  108. 


132  DIFFERENTIAL  DIAGNOSIS. 

A  remarkable  case,  illustrative  of  the  foregoing  statements,  has 
been  reported  by  Dr.  Stephen  Mackenzie.  ^ 

Tlu  Differential  Diagnosis  of  Intracranial  Tiimour  and  Migraine. 

In  typical  cases  of  ordinary  migraine  the  distinction  is  easily 
enough  made,  but  in  irregular  forms  there  may  be  great  difficulty  in 
arriving  at  a  positive  conclusion.  Further,  it  must  be  remembered 
that  a  patient,  who  has  for  years  been  subject  to  ordinary  migraine, 
may  subsequently  be  affected  with  an  intracranial  tumour.  In  cases 
of  this  kind,  unless  the  symptoms  are  very  clearly  marked,  the 
tumour  may  easily  be  overlooked.  This  is  particularly  apt  to  be  the 
case  when  there  is  no  optic  neuritis. 

The  markedly  periodic  character  of  the  attacks  of  headache  and 
vomiting ;  the  exact  character  of  the  pain  and  its  localisation  ;  the 
presence  of  temporary  hemianopsia,  fortification  vision,  &c.,  at  the 
onset  or  during  the  attack  ;  the  protracted  course  of  the  case ;  and 
the  fact  that  between  the  paroxysms  there  are  no  indications  of  intra- 
cranial mischief,  are  strongly  in  favour  of  migraine — a  condition 
which  is  not  infrequently  hereditary.  The  diagnosis  of  migraine  is 
strengthened  or  confirmed  by  the  absence  of  distinct  evidence  of 
organic  disease — in  particular,  by  the  absence  of  double  optic  neuritis 
and  of  localising  symptoms;  and  in  some  cases  by  the  effects  of 
treatment.  (Some  cases  of  migraine  speedily  yield  to  guaranina  or 
antifebrin  given  at  the  commencement  of  the  attack,  and  to  the 
systematic  administration  of  arsenic  or  other  nerve  tonics  during 
the  intervals.) 

In  those  cases  in  which  symptoms  of  migraine  are  associated  with 
hysteria  or  great  general  nervousness,  the  difficulty  of  diagnosis  is 
much  increased. 

Further,  it  must  be  remembered  that  in  some  cases  of  tumour 
the  headache  closely  resembles  that  of  ordinary  migraine  ;  indeed,  no 
less  an  authority  than  the  late  Dr.  Hilton  Fagge  supposed  (as  has 
been  stated  on  page  27)  that  the  headache  of  tumour  and  of  migraine 
are  produced  in  exactly  the  same  manner. 

^  Brain,  vol.  vii.,  p.  257. 


INTRACRANIAL  TUMOUR  AND  HYSTERIA.  133 

The,  Differential  Diagnosis  of  Intracranial  Tumour  and  Hysteria. 

Hysterical  symptoms  are  not  infrequently  associated  with  intra- 
cranial tumour,  and  indeed  with  all  forms  of  organic  disease  ;  and  in 
some  cases,  in  which  the  symptoms  and  signs  of  hysteria  are  promi- 
nent and  the  symptoms  and  signs  of  the  organic  lesion  (tumour),  with 
which  the  hysteria  is  associated,  are  ill  developed,  the  differential 
diagnosis  may  be  a  matter  of  extreme  difficulty  ;  in  some  cases  it  may 
be  impossible  to  come  to  a  positive  conclusion. 

The  diagnosis  of  an  intracranial  tumour  in  a  person  of  highly 
neurotic  temperament  is,  in  the  absence  of  optic  neuritis  and  positive 
evidence  of  localised  organic  disease,  extremely  difficult.  In  cases  of 
this  description  it  is  very  difficult  to  decide  what  value  should  be 
attached  to  headache  and  other  subjective  symptoms. 

In  all  doubtful  cases,  therefore,  the  observer  must  endeavour  to 
make  himself  familiar  with  the  original  (normal)  mental  constitution 
of  the  patient,  in  order  that  he  may  be  able  to  attach  the  true  value 
to  her  symptoms  and  complaints. 

In  dealing  with  persons  who  are  highly  neurotic  or  distinctly 
hysterical,  it  is  essential  to  remember  that  the  diagnosis  of  mere 
hysteria  (nothing  more  than  hysteria)  is  never  justified,  unless  the 
observer  has,  after  repeated  examinations,  failed  to  detect  symptoms 
or  signs  indicative  of  organic  disease. 

The  condition  of  the  optic  discs  is  without  doubt  the  most  impor- 
tant point  in  clearing  up  the  diagnosis.  The  presence  of  double  optic 
neuritis  enables  the  observer  to  decide  in  favour  of  tumour,  for  this 
symptom  is  very  rarely,  if  ever,  associated  with  mere  hysteria  alone. 
It  will  be  observed  that  I  do  not  say  double  optic  neuritis  is  never 
associated  with  mere  hysteria.  For  not  only  would  such  a  dogmatic 
method  of  statement  be,  in  my  opinion,  highly  unscientific,  but  I  am 
personally  disposed  to  think  that  it  would,  as  a  matter  of  fact,  in  this 
case  be  erroneous,  or  apparently  erroneous.  Double  optic  neuritis,  as 
we  have  seen,  is  occasionally  met  with  in  anaemia,  and  in  association 
with  disordered  menstruation,  with  errors  of  refraction,  and  with  some 
other  conditions,  such  as  diffused  cerebritis,  in  which  there  is  no 
"  coarse "  intracranial  lesion,  and  with  which  hysterical  symptoms 
are  not  infrequently  associated.      Now  in  such  cases  the  Iiysterical 


134  DIFFERENTIAL  DIAGNOSIS. 

condition  may  easily  appear  to  be  the  only  cause  for  the  ocular  change. 
Further,  we  are  still  in  doubt  as  to  the  exact  pathology  of  hysteria 
and  hysterical  symptoms  (hysterical  paralysis,  hysterical  contracture, 
hysterical  anaesthesia)  on  the  one  hand,  and  of  the  double  optic 
neuritis  associated  with  cerebral  tumours  on  the  other.  In  the 
presence  of  such  ignorance,  it  would,  in  my  opinion,  be  rash 
and  uuscientihc  to  affirm  that  the  same  (?)  functional  alterations 
which  produce  hysterical  paralysis,  hysterical  contracture,  or  hys- 
terical aucesthesia,  cannot  possibly  lead  to  the  production  of  some 
swelling  of  the  optic  papilla.  My  own  view  is  that  papillitis  is 
not  at  all  likely  to  be  produced  in  this  way ;  but,  as  has  been  pre- 
viously stated,  Dr.  Hughlings  Jackson  and  some  other  eminent 
authorities  consider  the  vaso-motor  theory  as  to  the  mode  of  produc- 
tion of  optic  neuritis  the  best  that  has  yet  been  advanced.  And  if  it  is 
granted  that  organic  disease  can  produce  papillitis  in  this  way,  it 
must  perhaps  be  allowed  that  the  functional  alterations  in  the  nerve 
centres,  which  are  the  cause  of  hysteria,  may  also  produce  vascular 
changes  (oedema  and  inflammation)  in  the  optic  discs. 

Personally  I  am  disposed  to  think  that  the  functional  changes  in 
the  nerve  centres,  which  produce  hysterical  paralysis  or  hysterical 
contracture,  are  not  in  the  least  likely  to  lead  to  the  production  of 
double  optic  neuritis ;  but  while  holding  this  view,  I  cannot,  for  the 
reasons  given  above,  assert  dogmatically  that  double  optic  neuritis  is 
never  associated  with  mere  hysteria  alone,  or  that  it  cannot  possibly  be 
produced  in  this  manner.  ^ 

But  be  this  as  it  may,  double  optic  neuritis  is  so  rarely,  if  ever, 
met  with  in  connection  with  mere  hysteria,  and  so  commonly  asso- 
ciated with  intracranial  tumours,  that  its  presence  (in  a  case  in  which 
the  diagnosis  lies  between  hysteria  and  cerebral  tumour)  practically 
settles  the  question,  and,  in  the  present  state  of  our  knowledge,  may 
be  taken  as  a  definite  indication  that  the  case  is  not  one  of  mere 
hysteria  alone. 

^  The  experience  of  any  single  observer  is  necessarily  so  limited,  and  the  knowledge 
which  can  be  acquired  by  making  oneself  familiar  vdih.  the  accumulated  experience  of 
authorities,  is,  when  compared  vdih.  the  facts  and  possibilities  of  nature,  so  imperfect,  that 
I  question  whether  such  terms  as  never,  cannot,  and  the  hke  should  ever  be  used  in  an 
unlimited  and  unqualified  sense.  It  is  of  course  quite  another  thing  to  use  these  terms 
in  a  limited  and  qualified  manner,  and  to  say,  for  instance,  so  far  an  I  know,  or  so  far  as 
is  known,  such  and  such  symptoms  never  or  cannot  occur  in  such  and  such  conditions 


INTRACRANIAL  TUMOUR  AND  HYSTERIA.  135 

But  while  the  ophthalmoscope  enables  us  to  clear  up  the  diagnosis 
in  those  cases  in  which  double  optic  neuritis  is  present,  it  does  not  of 
course  enable  us  to  make  a  diagnosis  in  all. 

In  those  cases  in  which  there  is  no  double  optic  neuritis,  the 
severity  of  the  headache  is  a  point  of  some  importance ;  but  in 
hysterical  and  neurotic  patients  it  is  often  (as  has  been  already 
pointed  out)  a  difficult  matter  to  gauge  the  severity  of  the  headache 
and  other  subjective  symptoms.  The  purposeless  vomiting,  too,  which 
is  so  highly  suggestive  of  organic  cerebral  disease,  may  be  exactly 
simulated  by  the  vomiting  of  hysteria;  while  the  convulsive 
seizures  of  hysteria  and  of  organic  disease  are  sometimes  difficult  to 
differentiate,  more  especially  when  they  are  not  seen  by  the  physician 
himself.  Again,  in  hysteria,  paralyses  (which  in  some  cases  are  most 
difficult  to  distinguish  from  the  paralyses  due  to  organic  disease)  may 
be  present. 

Localised  epileptiform  convulsions,  or  a  distinct  epileptic  fit,  are 
strongly  suggestive  of  organic  disease.  Localised  paralysis  of  the 
muscles  supplied  by  a  cranial  nerve  (though  not  very  common  in 
cases  of  tumour)  is,  when  present,  of  the  greatest  diagnostic  value ; 
for,  wliile  paralysis  of  the  limbs  is  not  uncommon  in  hysteria,  paralysis 
of  the  face  is  rarely  observed  even  in  hysterical  hemiplegia;  and 
isolated  paralysis  of  muscles  supplied  by  motor  cranial  nerves,  such 
as  the  facial,  is  very  rarely  due  to  hysteria  alone. 

In  doubtful  cases,  a  careful  study  of  the  distribution  of  the 
paralysis,  of  the  state  of  the  reflexes,  and  indeed  of  the  condition  of 
the  whole  nervous  system,  together  with  a  judicial  survey  of  the 
previous  history,  whole  progress,  and  course  of  the  case,  will  generally 
enable  the  physician  to  come  to  a  positive  conclusion  as  to  whether 
the  case  is  merely  one  of  hysteria  alone,  or  whether,  in  addition  to 
the  hysterical  symptoms  or  general  neurotic  (nervous)  condition, 
there  is  not  some  associated  organic  disease  {e.g.-,  tumour). 

In  all  doubtful  cases,  a  history  of  the  previous  removal  of  a  tumour, 
the  fact  that  there  is  a  new  growth  in  some  other  organ,  or  the  pre- 
sence of  a  constitutional  state,  which  is  likely  to  predispose  to  the 
production  of  certain  forms  of  new  growths  (such  as  the  syphilitic 
and  scrofulous),  should  be  diligently  inquired  for. 


136  DIFFERENTIAL  DIAGNOSIS. 

The  Differential  Diagnosis  of  Intracranial  Tumour  and  some  forms 

of  Insanity. 

Provided  that  the  physician  is  acquainted  with  the  previous 
history  and  course  of  the  case,  there  is  seldom  any  difficulty  in  dis- 
tinguishing these  conditions. 

In  the  later  stages  of  those  cases  of  tumour  in  which  the  mental 
deterioration  is  extreme,  the  patient  may  make  no  complaints,  and 
the  symptoms  of  "  coarse  "  lesion  may  be  so  little  marked  as  to  pass 
unnoticed.  It  is  obvious  that  under  such  circumstances  the  condi- 
tion may  be  mistaken  for  ordinary  dementia  {i.e.,  dementia  without 
"coarse"  organic  disease),  and  an  erroneous  diagnosis  arrived  at, 
should  the  physician  be  unacquainted  with  the  earlier  symptoms  of 
the  case. 

Again,  in  those  rare  cases  of  intracranial  tumour  in  which 
maniacal  symptoms  are  developed,  unless  the  previous  history  and 
course  of  the  case  are  known  to  the  physician,  the  presence  of  a 
tumour  may  be  unsuspected. 

If  Lautenbach's  observations,  which  show  that  well  -  marked 
double  optic  neuritis  is  present  in  about  16  per  cent  of  cases  of  acute 
mania,  are  confirmed,  the  distinction  of  acute  mania  with  "  coarse  " 
organic  disease,  from  acute  mania  without  "  coarse "  organic  disease, 
will,  in  the  absence  of  a  definite  history  of  previous  symptoms  of 
organic  lesion  (severe  headache,  vomiting,  and  localising  symptoms), 
be  practically  impossible. 

The  Differential  Diagnosis  of  Intracranial  Tumour  and  of  Meningitis. 

This  is  in  most  cases  easy,  in  some  most  difficult,  and  in  others 
impossible.     In  many  cases,  indeed,  the  two  conditions  are  combined. 

In  some  cases  it  is  impossible  to  draw  a  distinction  during  life 
between  a  syphilitic  cerebral  tumour  (gumma)  and  syphilitic  menin- 
gitis, or  between  a  tubercular  tumour  and  a  localised  tubercular 
meningitis,  more  especially  of  the  convexity. 

The  diagnosis  is  especially  difficult  in  those  cases  of  meningitis 
(and  they  are  usually  tubercular  or  syphilitic)  which  run  a  protracted 
(subacute  or  chronic)  course,  on  the  one  hand ;  and  in  those  cases  of 


INTRACRANIAL  TUMOUR  AND  MENINGITIS.       137 

cerebral  tumour,  on  the  other,  which  rapidly  develop,  which  follow 
injury,  and  which  are  associated  with  meningitis  or  cerebritis. 

In  both  conditions  (tumour  and  meningitis)  headache,  vomiting, 
double  optic  neuritis,  and  general  or  localised  convulsive  seizures, 
may  be  prominent  symptoms ;  and  in  some  cases  of  meningitis  there 
may  even  be  localised  paralysis. 

The  cases  in  which  a  distinction  can  usually  be  made  are  cases  of 
cerebral  tumour  on  the  one  hand,  and  generalised  meningitis  on  the 
other. 

The  chief  points  to  which  attention  should  be  directed  in  order  to 
differentiate  the  two  conditions  are — 

1.  The  mode  of  onset,  eourse,  and  duration  of  the  case. — In  ordinary 
typical  cases  of  tubercular  meningitis,  such  as  occur  in  children,  the 
onset  is  as  a  rule  much  more  sudden ;  the  symptoms  advance  much 
more  steadily  and  progressively  from  bad  to  worse,  a  distinct  stage  of 
irritation  usually  preceding  a  stage  of  depression;  and  the  whole 
duration  of  the  case,  averaging  as  it  does  about  two  weeks,  is  much 
shorter  than  that  of  most  cases  of  intracranial  tumour. 

In  quite  exceptional  cases  tubercular  meningitis  runs  a  much  more 
protracted  course.  The  diagnosis  is  then  much  more  difficult.  I  have 
myself  reported  a  case  of  meningitis  (I  believe  from  the  post-mortem 
evidence  tubercular)  in  which  the  inflammatory  symptoms  gradually 
subsided  and  the  patient  died  six  months  after  the  onset  of  the 
attack,  from  hydrocephalus,  secondary  to  the  meningeal  inflammation. 
A  duration  of  more  than  six  weeks  is  strongly  against  meningitis. 
With  regard  to  this  point  the  late  Dr.  Hilton  Fagge  says,  "  ISTow  I 
believe  it  may  be  said  that  wherever  cerebral  symptoms  of  the  kind 
described  in  this  chapter  {i.e.,  symptoms  characteristic  of  an  intra- 
cranial tumour)  have  lasted  for  more  than  five  or  six  weeks,  the  only 
other  organic  affections  of  the  brain  by  which  they  can  be  caused  are 
abscess  and  certain  diffused  morbid  changes."  ^ 

While  personally  I  am  not  prepared  to  endorse  to  the  full  this 
statement,  I  nevertheless  admit  the  great  diagnostic  importance  of  a 
protracted  course  {i.e.,  of  a  duration  of  more  than  six  weeks). 

A  careful  inquiry  into  the  exact  mode  of  onset  of  the  attack  and 
the  previous  condition  of  the  patient  is  of  great  importance  ;  for  cases 

'  Pnnciples  and  Practice  of  Medicine,  vol.  i.,  p.  539. 


138  DIFFERENTIAL  DIAGNOSIS. 

of  intracranial  tumour  are  sometimes  met  with,  in  which  the  onset 
appears  to  be  acute,  and  attended  with  febrile  symptoms.  In  almost 
all  cases  of  this  kind,  which  are  very  liable  to  be  mistaken  for  cases  of 
meningitis,  a  careful  inquiry  will  usually,  I  believe,  elicit  a  history 
of  previous  cerebral  symptoms  (headache,  vomiting,  slight  mental 
alterations,  &c.).  In  the  great  majority  of  cases  of  this  kind  the 
tumour  has  been  slowly  developing  (-without,  perhaps,  producing  any 
marked  cerebral  disturbance)  for  some  time  before  the  apparent  acute 
onset,  which  is  usually  due  to  the  occurrence  of  meningitis,  cerebritis, 
or  some  other  acute  change  in  the  neighbourhood  of  the  new  growth. 

In  very  rare  cases  a  patient  who  is  already  the  subject  of  com- 
mencing cerebral  disease  (tumour)  receives  a  head  injury,  which  is 
followed  by  well-marked  symptoms  of  meningitis.  Unless  the  condi- 
tion of  the  patient  prior  to  the  receipt  of  the  injury  is  carefully  elicited, 
it  is  quite  obvious  that  the  meningitis  may,  under  such  circumstances, 
be  considered  the  primary  lesion,  and  the  previous  disease  (tumour) 
overlooked.  I  have  known  a  case  of  this  kind  in  which  a  patient, 
already  the  subject  of  a  cerebral  tumour,  fell  (apparently  in  conse- 
quence of  vertigo  or  an  epileptic  fit)  and  severely  injured  his  head,  the 
injury  being  followed  by  well-marked  cerebral  symptoms. 

In  cerebro-spinal  meningitis  the  onset  is,  as  a  rule,  even  more 
sudden,  the  symptoms  more  rapidly  progressive,  and  the  duration 
shorter  than  in  tubercular  meningitis.  There  is  not  much  likelihood 
of  confounding  cases  of  this  kind  with  cases  of  intracranial  tumour. 

In  some  of  the  cases  in  which  the  onset  is  more  or  less  sudden, 
and  symptoms  common  both  to  meningitis  or  tumour  (headache, 
vomiting,  optic  neuritis,  vertigo,  &c.)  are  developed,  the  headache  and 
other  symptoms  disappear,  the  optic  neuritis  completely  subsides,  and 
the  recovery  may  be  perfect.  In  cases  of  this  kind  I  am  disposed 
to  think  that  the  lesion  was  more  probably  meningitis,  often 
syphilitic  meningitis,  rather  than  tumour.  It  must,  however,  be 
admitted  that  the  lesion  may  have  been  a  syphilitic  gumma ;  but 
other  tumours  may,  I  think,  be  excluded,  for  all  pathologists  know 
that  nothing  is  more  rare  than  to  find  the  remains  of  a  cured 
tumour  (other  than  a  syphilitic  gumma)  within  the  skull ;  and 
if  the  cases  I  am  now  referring  to  were  due  to  a  "coarse"  lesion 
(tumour),  the  remains  of  cured  tumours  ought  occasionally  to  be  found. 


INTRACRANIAL  TUMOUR  AND  MENINGITIS.       139 

Some  of  our  best  authorities  differ  from  this  opinion,  and  think 
that  in  such  cases  the  pathological  condition  was  tumour  ("  coarse  " 
disease)  rather  than  meningitis.  Dr.  Hughlings  Jackson,  for  example, 
says — "  Suppose  next  that  there  was  an  acute  ilhiess  from  which  the 
patient  has  recovered,  except  for  defective  sight,  with  some  atrophy  of 
the  optic  discs.  Here  comes  the  question,  was  the  illness  in  either 
this  or  the  former  case  meningitis  ?  For  my  own  part,  I  believe  it  to 
be  more  probable  that  it  was,  and  remains  a  case  of  local,  gross  organic 
disease,  such  as  tumour.  It  is  of  no  avail  to  say  of  the  acute  case 
that  the  patient  had  all  the  symptoms  of  a  meningitis,  for  there  are 
no  symptoms  known  to  be  characteristic  of  meningitis  only.  Admitting 
that  during  the  illness  we  might  be  unable  to  decide,  I  should  take 
the  mere  fact  of  recovery  as  strong  evidence  against  meningitis  ;  not 
that  I  need  deny  that  recovery  from  meningitis  occasionally  happens. 
Virchow  speaks  of  recovery  from  tubercular  meningitis.  Autopsies 
alone  can  decide.  So  far  as  autopsies  go  (made  some  time  after 
recovery  on  return  of  head  symptoms,  or  after  death  by  other 
cause),  the  evidence  is  in  favour  of  local,  gross  organic  disease,  rather 
than  of  meningitis  in  cases  of  the  kind  referred  to.  I  feel  sure,  at  any 
rate,  that  facts  show  that  even  complete  recovery,  with  good  sight, 
does  not  negative  persisting  local,  gross  organic  disease  within  the 
cranium.  This  is  strikingly  true  of  some  cases  of  syphilitic  tumour ; 
the  symptoms  pass  off  under  treatment,  but  the  patient  may  come 
again  and  again  for  the  same  localising  symptom  (for  convulsions 
beginning  in  one  hand,  let  me  instance),  showing  disease  persisting  in 
one  place,  as  in  a  striking  case  (of  which  I  am  thinking)  the  necropsy 
proved.  So,  instead  of  asking  for  evidence  from  cases  of  patients  who 
have  recovered  from  symptoms  of  meningitis,  I  ask  the  question, 
Have  traces  of  meningitis  been  found  after  such  recoveries,  when 
patients  have  died  later,  or  of  some  other  disease  ? "  ^ 

2.  The  hehaviour  of  the  temperature  and  pulse. — Elevation  of  tem- 
perature, and  increased  irequency  of  the  pulse  in  the  early  stages, 
followed  by  slowing  and  irregularity  in  the  after  periods,  are  in  favour 
of  meningitis  rather  than  of  tumour.  When  the  tumour  is  compli- 
cated with  meningitis  or  cerebritis,  there  may  of  course  be  some  febrile 
disturbance,  but  it  is  seldom  prominent. 

^  Transactions  of  the  Ophtkaltnoloyical  Society  of  the  Uaited  Kingdom,  voL  i.,  p.  73. 


I40  DIFFERENTIAL  DIAGNOSIS. 

3.  The  severity  and  character  of  the  headache. — These  are  sometimes 
of  importance.  Very  severe  and  localised  headache  is  certainly  in 
favour  of  tumour.  In  meningitis  there  is  usually,  I  think,  more  hyper- 
sensitiveness  to  light,  noise,  &c.,  than  in  tumour. 

4.  Tlic  degree  of  oj^tic  neuritis,  and,  in  tubercular  cases,  the  presence 
of  tubercles  in  the  choroid. — In  rapid  cases  of  tubercular  and  other 
forms  of  meningitis,  optic  neuritis  is  seldom  present,  but  in  the  more 
protracted  cases  it  is  often  observed.  In  tubercular  cases  the  degree 
or  intensity  of  the  neuritis  is  seldom  so  great  as  in  cases  of  tumour. 
The  intensity  of  the  neuritis  is  not,  however,  an  absolutely  safe  guide, 
for  in  cerebral  tumours  the  neuritis  may  of  course  be  slight,  while  in 
some  cases  of  meningitis^  (tubercular  and  other)  the  most  intense 
neuritis,  followed  by  optic  atrophy,  is  observed.  "Apart  from  the  distin- 
guishing characters  afforded  by  the  degree  of  the  neuritis,"  Dr.  Gowers 
states  that  he  has  "noted  only  one  difference  between  the  neuritis 
caused  by  tumour  and  that  due  to  meningitis,  viz.,  that  during  the 
early  stage  of  inflammation,  when  it  is  coming  on  and  the  swelHng  is 
distinct,  the  papilla  is  paler  in  meningitis  than  in  tumour."  ^ 

Dr.  Hughhngs  Jackson  states  that  "  in  tubercular  meningitis  the 
swelling  is  slight,  not  extensive ;  it  is  even,  merges  into  the  fundus ; 
the  disc  is  succulent-looking ;  there  is  not  time  possibly  for  further 
development.  It  is  hke  the  earliest  stage  of  optic  neuritis  from  intra- 
cranial tumour."  3 

In  long-continued  cases  of  tubercular  meningitis,  tubercles  are  not 
infrequently  found  in  the  choroid  on  post-mortem  examination  ;  their 
detection  during  life,  while  it  would  undoubtedly  show  the  patho- 
logical nature  of  the  lesion,  and  would  be  in  favour  of  meningitis 
rather  than  tumour,  would  not  necessarily  exclude  a  scrofulous  tumour, 
with  which  tubercles  in  the  choroid  may  of  course  be  associated. 

In  two  cases  in  which  nuqierous  large  white  spots  were  present 
in  the  neighbourhood  of  the  macula,  I  had  considerable  difficulty  in 
deciding  whether  they  were  in  the  retina  and  due  to  Bright's  disease, 
or  whether  they  were  tubercles  in  the  choroid — a  difficulty  which  in 
one  of  the  cases  was  also  shared  by  an  experienced  observer. 

^  See  a  case  reported  by  me  in  the  Edinhtrgh  Medical  Journal  for  August  1879. 
-   Transactions  of  the  Ophthalinological  Society  of  the  United  Kiivgdom,  vol.  i.,  p.  104. 
»  Ibid.,  p.  64. 


INTRACRANIAL  TUMOUR  AND  ABSCESS.  141 

The  presence,  then,  of  tubercles  in  the  choroid  is  in  favour  of 
meningitis,  but  does  not  exclude  tumour. 

5.  Tlie  age  of  the  'patient. — This  is  of  some  importance,  for  in  young 
children  tubercular  meningitis  is  more  common  than  tubercular 
tumour,  while  in  adults  the  reverse  is  the  case. 

T}ie  Differential  Diagnosis  of  Intracranial  Tumour  and  of  Cerebral 
or  Cerebellar  Abscess. 

In  some  cases  the  distinction  is  extremely  difficult,  indeed  it  may 
be  impossible.  An  encapsuled  abscess  must  in  fact  be  looked  upon 
as  a  (cystic)  tumour,  and  may  be  associated  with  the  ordinary  symptoms 
of  a  new  growth — headache,  vomiting,  optic  neuritis,  vertigo,  &c. 

In  order  to  differentiate  the  two  conditions,  attention  should  be 
chiefly  directed  to  the  following  points : — 

1.  The  presence  or  absence  of  a  cause  of  abscess. — Cerebral  abscesses 
very  rarely  develop  per  se,  but  usually  have  their  starting-point  in 
suppurative  disease  of  the  ear,  nose,  or  some  other  part  of  the  cranial 
bones.  In  some  cases  abscess  is  secondary  to  an  injury  of  the  head. 
In  others  a  lesion  within  the  thorax,  more  especially  lung  disease,  is 
the  source  of  origin. 

In  other  cases — but  these  I  do  not  include  in  speaking  of  localised 
cerebral  abscess — the  cerebral  lesion  is  part  and  parcel  of  a  general 
pysemia;  in  cases  of  this  kind  the  abscesses  are  almost  always 
multiple,  usually  of  small  size,  and  generally  associated  with  diffuse 
meningitis  or  cerebritis,  or  both. 

In  all  cases,  therefore,  in  which  there  is  any  doubt  as  to  the 
diagnosis,  the  condition  of  the  ear,  nose,  and  other  parts  of  the  skull 
should  be  carefully  examined ;  in  fact,  I  never  commit  myself  to  a 
positive  diagnosis  of  intracranial  tumour,  unless  I  have  excluded  sup- 
purative ear  and  nose  disease. 

In  those  cases  in  which  a  local  cause  of  abscess  (such  as  suppura- 
tive ear  disease)  is  present,  in  addition  to  the  general  symptoms 
suggestive  of  tumour  or  abscess  (headache,  vomiting,  and  it  may  be 
double  optic  neuritis),  the  chances  are  strongly  in  favour  of  abscess 
rather  than  of  tumour.  It  is  of  course  possible  to  have  an  intra- 
cranial tumour  and  an  otorrhcea  (or  other  local  cause  of  cerebral 
abscess)  accidentally  associated,  but  the  chances  are  strongly  against 


142  DIFFERENTIAL  DIAGNOSIS. 

such  an  accidental  occurrence.  Vice  versa,  when  no  discoverable  local 
cause  (source)  of  abscess  is  present,  the  chances  are,  other  things  being 
equal,  very  strongly  in  favour  of  tumour,  and  the  correct  diagnosis  of 
cerebral  abscess  in  such  circumstances  {i.e.,  in  the  absence  of  disease 
of  the  ear,  nose,  or  cranial  bones,  and  of  traumatic  injury)  is  seldom 
more  than  a  fortunate  guess. 

2.  Tlu  'pi'cvious  fiistory,  ivhole  lyfogress,  and  course  of  the  case. — This 
may  throw  light  on  doubtful  cases ;  when  no  clear  or  reliable  eA'idence 
is  forthcoming  the  difficulties  of  diagnosis  are  much  increased, 

A  history  of  former  ear  disease,  with  the  subsequent  long  continu- 
ance of  cerebral  symptoms,  is  in  favour  of  abscess.  The  rapidity  with 
which  the  symptoms  progress  does  not  afford  any  certain  guide,  for  in 
some  cases  of  encapsular  abscess  (i.e.,  while  the  abscess  is  still  encap- 
suled  and  unassociated  with  cerebritis,  meningitis,  or  sinus  phlebitis) 
the  course  of  the  cases  is  very  chronic,  and  there  may  be  few,  if  any, 
characteristic  symptoms.  In  tumour,  the  same  absence  of  striking 
symptoms  may  also  of  course  be  observed.  In  tiunour,  headache  is,  I 
think,  usually  more  severe.  This  statement,  as  the  former,  only 
applies  to  encapsuled  abscesses  (while  stiU  encapsuled),  for  I  have 
known  the  most  intense  headaches  which  it  is  possible  to  conceive  in 
cerebral  abscess.  In  the  case  to  which  I  refer  there  were  three  sepa- 
rate abscesses  (one  in  the  frontal,  one  in  the  temporo-sphenoidEd  lobe> 
and  one  in  the  cerebellum). 

Double  optic  neuritis  is  also,  I  think,  more  frequent  in  tumour. 
Possibly  unilateral  optic  neuritis  may  be  in  favour  of  abscess ;  but 
more  information  is  required  before  it  is  possible  to  generalise  on 
this  point. 

The  temperature  may  afford  no  guide  ;  for  in  encapsuled  abscess, 
as  in  tumour,  it  is  usually  normal  or  subnormal.  A  suppurative 
temperature,  with  rigors  and  sweatings,  is  of  course  strongly  in 
favour  of  abscess.  Emaciation  without  sufficient  apparent  cause  is 
perhaps  suggestive  of  abscess. 

In  a  doubtful  case,  the  sudden  occurrence  of  symptoms  indicative 
of  severe,  diffuse  meningitis  would  be  strongly  in  favour  of  abscess. 
Symptoms  and  signs  of  sinus  phlebitis  also,  of  course,  point  strongly 
to  abscess. 

The  situation  of  the  lesion  is  a  matter  of  some  importance ;  for 


EXTRA-  AND  INTRACRANIAL  SYPHILIS.  143 

abscesses  are  in  the  great  majority  of  cases  situated  either  in  the 
temporo-sphenoidal  lobe  or  the  cerebellnm  ;  the  location  of  the  lesion 
in  some  other  part  of  the  brain  is  therefore  in  favour  of  tumour. 

The,  Differential  Diagnosis  of  Extra-  and  Intracranial  Syphilis. 

In  some  cases  of  extracranial  syphilis,  in  which  the  headache  is 
severe,  the  tenderness  of  the  scalp  great,  the  periosteal  thickening 
evident,  and  the  patient  exhausted  by  sleeplessness  and  suffering,  both 
the  patient  and  the  physician  may  suspect  the  presence  of  an  intra- 
cranial  lesion.  The  suspicion  is  not  unnatural ;  for  intracranial  nodes 
or  other  intracranial  syphilitic  lesions  are  frequently  combined  with 
extracranial  syphilis.  Difficulties  in  diagnosis  are  especially  apt  to 
occur  in  those  cases  in  which  a  periosteal  lesion,  surrounding  the 
orifice  of  exit  of  a  cranial  nerve,  produces  well-marked  and  localised 
paralysis  or  anaesthesia.  The  points  to  which  attention  is  chiefly  to 
be  directed  in  making  the  differential  diagnosis  are — 

1.  The  condition  of  the  optic  discs. 

2.  The  presence  or  absence  of  definite  cerebral  symptoms,  such 
as  vomiting,  vertigo,  paralysis,  or  anaesthesia  of  cerebral  distribution, 
spasms  or  convulsive  twitchings,  hemianopsia,  &c. 

3.  The  therapeutic  effects  of  a  vigorous  anti-syphilitic  treatment. 
The  fact  that  as  the  external  nodes  disappear  the  headache  and  other 
symptoms  entirely  subside,  does  not  of  course  prove  that  the  lesion 
is  entirely  extracroxnal ;  for  under  the  influence  of  large  doses  of 
iodide  of  potassium  (at  least  a  drachm  and  a  half  daily)  internal 
syphilitic  lesions  often  clear  up  with  great  rapidity.  But  the  fact 
that,  with  the  disappearance  of  the  external  manifestations,  the 
headache  and  other  cerebral  symptoms  entirely  subside,  is  very 
suggestive  that  the  lesion  is  extracranial  only ;  for  the  meningitic  and 
vascular  (cerebral)  lesions  seldom  clear  up  with  the  same  rapidity  as 
the  periostitis. 

The  Differential  Diagnosis  of  Cerebral  Tumour  and  Cerebral 
Hoemorrhage. 

The  distinction  is  usually  easy,  provided  that  the  previous  history 
of  the  case  is  accurately  known. 

The  strong  probability  is,  of  course,  that  an  apoplectic  attack  in 


144  DIFFERENTIAL  DIAGNOSIS. 

a  patient  (previously  unknown  and  about  whom  no  history  is  forth- 
coming) is  due  to  ordinary  cerebral  haemorrhage,  rather  than  to  a 
haemorrhage  or  to  a  pseudo-apoplectic  attack  associated  with  tumour. 
The  physician  who  aims  at  being  as  correct  as  possible  in  every  case, 
will  not,  however,  rest  satisfied  with  mere  probabilities,  but  will  try  to 
make  an  exactly  accurate  diagnosis  in  every  case.  And  there  can  be 
little  doubt  that  ha?morrhages  from  vascular  gliomata  have  not  infre- 
quently been  mistaken  both  during  life  and  after  death  for  ordinary 
ha?morrhagic  apoplexies. 

The  chief  points  to  which  attention  should  be  directed  in  order  to 
distimruish  the  conditions  are — 

1.  Tlie,  history  of  tlie  case  and  mode  of  onset  of  the  attach. — In 
those  cases  in  which  the  symptoms  of  cerebral  tumour  are  well 
marked,  and  the  history  of  the  case  is  known  to  the  physician,  there 
is  little  or  no  difiiculty. 

"^^lien  an  apoplectic  attack  has  been  preceded  by  attacks  of 
headache,  vomiting,  &c.,  the  possibility  of  intracranial  tumour  should 
always  be  kept  in  view.  (Bright's  disease  may,  as  has  been  previously 
pointed  out,  produce  the  same  symptoms.) 

2.  Tlie  condition  of  the  ojJtie  discs. — The  presence  of  double  optic 
neuritis  in  a  case  of  supposed  apoplexy  (ordinary  cerebral  hemorrhage) 
is  strongly  suggestive  of  the  presence  of  a  tumour  (more  especially  if 
there  is  no  renal  disease  and  no  plumbism),  for  cerebral  hsemorrhage 
per  se  is  seldom,  if  ever,  attended  with  double  optic  neuritis. 

3.  TJie  age  of  the  ixitient. — Ordinary  cerebral  haemorrhage  is 
rare  before  middle  age,  while  the  cerebral  hemorrhage  or  pseudo- 
apoplectic  attacks  connected  with  tumour  may  occur  at  any  age,  and 
are  just  as  frequent,  perhaps  even  more  frequent,  in  young  than  in 
old  people. 

4.  Tlie  condition  of  the  urine. — This  is  most  important,  for  in  many 
cases  of  ordinary  cerebral  hemorrhage  the  kidneys  are  cirrhotic. 

5.  TJie  2Jrcsence  of  associated  lesions,  such  as  are  to  be  met  with 
in  cases  of  tumour  on  the  one  hand  (syphilitic  or  scrofulous  lesions, 
sarcomatous  and  cancerous  deposits  in  other  organs),  and  of  ordinary 
cerebral  haemorrhage  on  the  other  (albimiinuria,  hypertrophy  of  the 
left  ventricle  without  vah-ular  disease,  high  arterial  tension,  albumi- 
nuric retinitis,  atheroma  of  the  peripheral  vessels,  &c.). 


CEREBRAL  TUMOUR— CEREBRAL  HEMORRHAGE.    145 

The,  differential  diagnosis  of  the  pseudo-apoplectic  attacks,  which  are 
so  common  in  some  forms  of  tumour,  more  especially  in  cases  of 
cerebral  syphilis,  and  of  apojjlectic  attacks  clue  to  hcemorrhagic  extra- 
vasations, such  as  occur  so  frequently  in  cases  of  glioma,  is  a  point  of 
some  importance ;  for  the  prognosis  is  markedly  different  in  the  two 
conditions, — pseudo-apoplectic  attacks  are  usually  recovered  from,  while 
apoplectic  seizures,  due  to  large  hsemorrhagic  extravasations  from  the 
vessels  of  a  tumour,  are  often  fatal. 

The  distinction  cannot  always  be  made  with  certainty  ;  the  chief 
points  to  which  attention  is  to  be  directed  are — 

1.  The  nature  of  the  tumour. — As  stated  above,  h?emorrhagic 
extravasations  are  chiefly  met  with  in  connection  with  glioma ;  but 
they  may  occur  in  cases  of  sarcoma  and  cancer, — in  short,  in  all 
cases  in  which  there  is  excessive  vascularity  either  in  or  around  a 
new  growth.  Pseudo-apoplectic  attacks,  though  probably  more  common 
in  syphilitic  than  in  other  forms  of  new  growth,  are  by  no  means 
distinctive  of  that  condition.  They  may  occur  in  cases  of  glioma, 
sarcoma,  cancer,  &c. 

2.  The  hehcwiour  of  the  temperature. — This  is  in  many  cases  a 
point  of  considerable  diagnostic  value;  for  in  pseudo  -  apoplectic 
seizures  the  temperature  alterations  which  occur  in  cases  of  large 
cerebral  haemorrhage  are  not  usually  observed. 

3.  The  progress  of  the  case. — In  pseudo -apoplectic  attacks,  the 
unconsciousness,  hemiplegia,  &c.  soon  pass  off  (provided,  of  course, 
that  the  patient  recovers  from  the  coma),  while  in  genuine  apoplectic 
seizures  the  unconsciousness  is  often  prolonged,  the  result  much  more 
frequently  fatal,  and,  if  the  patient  does  recover,  the  paralysis  is  much 
more  apt  to  remain. 

These  facts  are  of  importance  as  regards  prognosis,  for  in  cerebral 
syphilis  the  prognosis  is  never  absolutely  hopeless,  even  although  the 
unconsciousness  is  profound,  and  the  symptoms  apparently  most 
desperate. 


K 


CHAPTER     VIII. 

BlAGNOSlS—continued :    THE  L0CALI8ATI0X  OF  THE 
TUMOUE. 

Haying  decided  that  there  is  a  a  intracranial  tumour,  we  endeavour 
in  the  next  place  to  determine  its  exact  locality  or  site — a  point  of 
the  greatest  importance,  both  for  practical  (operative)  and  scientific 
purposes,  for  it  is  only  by  observing  the  effects  of  localised  brain 
lesions,  and,  as  Horsley  has  shown,  by  electrical  irritation  of  portions 
of  the  cortex  exposed  during  surgical  operations,  that  we  can,  in  man, 
determine  the  function  of  special  parts  of  the  brain  tissue. 
The  local  diagnosis  is  arrived  at  by  observing — 

1.  The  exact  nature  of  the  positive  localising  symptoms,  which 
show  derangement  of  function  in  special  parts  of  the  brain  tissue. 

2.  The  negative  indications,  or  absence  of  symptoms  indicative 
of  functional  derangement  of  special  parts. 

3.  The  manner  in  wliich  the  symptoms  (positive  and  negative) 
are  grouped  together,  and  the  order  in  which  tliey  are  developed. 

Chief  sources  of  error  in  determining  the  locality  of  tumours  and 
other  local  cerebral  lesions. — The  opinion  which  is  formed  as  to  the 
position  of  a  tumour  may  be  erroneous  for  several  reasons. 

In  the  first  place,  localising  symptoms  do  not  always  result  from 
destruction  of  important  cerebral  centres.  Xo  more  striking  illustra- 
tion could  be  given  than  the  case  of  destruction  of  the  motor  area 
without  paralysis,  which  is  represented  in  Figs.  1,  2,  S,  and  4,  pages 
11  to  14. 

In  the  second  place,  the  new  growth  may,  liy  altering  the  relation- 
ship of  the  intracranial  contents,  and  by  compressing  or  stretching 
the  nervous  tissues,  or  by  obstructing  the  blood  supply,  cause 
functional  disturbances  in  distant  portions  of  brain  tissue  (distant 
centres),  and  so  produce  j^seiido-loccdising  symptoms  (see  page  15). 


THE  LOCALISATION  OF  THE  TUMOUR.  147 

In  the  third  place,  the  tumour  may  in  some  cases  produce  pseuclo- 
localising  symptoms  by  reflexly  stimulating  or  inhiljiting  the  function 
of  distant  parts  (centres). 

In  the  fourth  place,  a  tumour  in  one  part  of  the  brain  may  pro- 
duce symptoms  suggestive  of  a  lesion  in  some  other  and  distant  part, 
by  involving  the  conducting  fibres  passing  to  or  from  that  part. 
Some  observers  think  that  tumours  or  lesions  of  the  angular  gyrus 
produce  hemianopsia  in  this  way,  viz.,  by  "  cutting  "  (implicating)  the 
radiating  fibres  of  Gratiolet  as  they  pass  backwards  to  the  half- vision 
centre  in  the  occipital  lobe.  Possibly  lesions  of  the  island  of  Eeil 
produce  some  forms  of  aphasia  in  the  same  manner,  viz.,  by  interrupt- 
ing the  fibres  wMch  connect  the  sensory  speech  centres  (situated  in 
the  angular  gyrus  and  first  temporo-sphenoidal  convolution)  with  the 
motor  speech  centre  (situated  in  the  posterior  third  of  the  lower 
frontal  convolution — see  Fig.  39,  page  116). 

Vice  versa,  lesions  (tumours)  in  the  centrum  ovale  may  gradually 
make  their  way  towards  the  cortex;  and,  by  causing  discharge  of 
cortical  centres,  may  lead  the  observer  to  suppose  that  the  tumour  is 
located  in  the  cortex  itself.  Xow,  in  cases  of  this  description, 
although  the  cortex  is  directly  involved  by  the  lesion  from  below,  no 
diseased  appearance  may  be  detectable  from  the  surface,  a  fact  of 
practical  importance ;  for,  when  the  symptoms  clearly  show  that  the 
function  of  a  given  portion  of  the  cortex  is  deranged,  the  operator 
should  not  rest  content  with  a  mere  surface  view,  but  should  explore 
the  condition  of  the  subcortical  tissue  (by  means  of  an  incision)  in 
those  cases  in  which  the  surface  of  the  brain  appears  to  be  healthy. 
In  Dr.  Hughes  Bennett's  case  (the  first  in  which,  so  far  as  I  know,  a 
cerebral  tumour  was  removed  by  operation),  the  superficial  appear- 
ances of  the  brain  were  quite  normal ;  and  it  was  only  when  an 
incision  was  made  through  the  cortex  that  the  tumour  was  discovered. 

At  post-mortem  examinations  it  is  often  difficult  to  determine 
the  exact  point  from  which  the  tumour  originated,  or  the  part  (centre) 
which  was  originally  invaded.  This  is  one  of  the  practical  difiiculties 
which  we  meet  with  in  trying  to  determine  the  function  of  individual 
parts  of  the  human  brain. 

In  the^y^A  place,  intracranial  tumours  are  not  infrequently  multiple, 
and  in  such  cases  exact  localisation  may  be  very  difficult,  or  impossible. 


148  DIAGNOSIS. 

The  chief  localising  symptoms,  which  have  already  been  considered 
in  detail,  are — 

1.  Symptoms  due  to  deranged  function  of  the  intracranial  motor 
nerve  apparatus  —  centres,  conductors,  and  (intracranial)  peripheral 
nerves — such  as  paralyses,  spasms,  convulsions,  tremors,  inco-ordina- 
tion,  motor  speech  alterations. 

These  symptoms  are  of  the  highest  localising  value,  for  our  know- 
ledge of  the  position  of  the  motor  centres  and  the  course  of  the 
motor-conducting  tracts  is  now  far  advanced,  and  the  symptoms 
which  result  from  their  derangement  are  distinct  and  easily  observed. 
The  more  limited  the  paralysis  or  spasm,  the  greater  of  course  its 
localising  value.  The  comparative  value  of  spasms  and  convulsions 
as  localising  symptoms  has  already  been  considered  (see  page  84). 

2.  Symptoms  due  to  deranged  function  of  the  intracranial  sensory 
nerve  apparatus — centres,  conductors,  and  (intracranial)  peripheral 
nerves — such  t\.s  anajsthesia  and  hyperesthesia  of  the  limbs,  anaes- 
thesia and  hyperaestliesia  in  the  area  of  distribution  of  the  fifth  nerve, 
hemianopsia,  word-deafness,  word-blindness,  &c. 

Sensory  derangements  are,  speaking  generally,  of  less  localising 
value  than  the  corresponding  motor  derangements,  for  the  following 
reasons : — 

(f/..)  They  do  not,  as  a  rule,  so  prominently  attract  the  attention 
either  of  the  patient  or  the  physician.  Headaclie,  neuralgia,  and 
liyperaesthetic  symptoms  generally  are,  of  course,  exceptions. 

(&.)  Tlieir  exact  extent  and  distribution  is,  in  many  instances, 
more  difficult  to  determine. 

(c.)  They  are  usually  more  transitory.  Their  centres  are  more 
widely  spread  out,  and  are  therefore  with  more  difficulty  destroyed. 
In  the  cases  of  the  special  senses  (touch  perhaps  excepted)  the  centres 
are  bilateral;  substitution  is  therefore  more  readily  established  by  the 
corresponding  centre  in  the  opposite  liemisphere  of  the  brain  carrying 
on  the  function  of  that  which  is  destroyed. 

(d)  In  the  case  of  some  of  the  sense  organs,  at  all  events,  the 
sources  of  peripheral  lesion  are  more  numerous.  Dimness  of  vision  and 
deafness  are,  for  instance,  more  easily  produced  by  peripheral  lesions  in 
the  eye  or  ear  (end-organs  of  sight  and  hearing),  than  paralysis  is  by  a 
peripheral  lesion  of  the  muscles  (motor  end-organs).     Again,  there  is 


THE  LOCALISATION  OF  THE  TUMOUR. 


149 


often  more  difficulty  in  deciding  whether  a  lesion  is  peripheral  in  the 
case  of  a  sensory  than  in  the  case  of  a  motor  mechanism.  By  observ- 
ing the  condition  of  nutrition,  the  state  of  the  electrical  reactions,  and 
the  condition  of  the  reflexes,  we  can  in  most  cases  readily  determine 
whether  a  paralysis  is  peripheral  or  not.  It  must,  of  course,  be  re- 
membered that  central  lesions  involvino-  the  nerve  nucleus  of  origin 


^^3:^— 


Fig.  45. — The  skull-cap  seen  from  above  in  a  case  of  extreme  distention 
of  the  ventricles,  the  result  of  a  scrofulous  tumour  of  the  cerebellum. 
(Copied  from  a  photograph. ) 

The  dark  shading  between  the  bones  of  the  skull  shows  the  degree  of 
separation  of  the  sutures. 

of  a  peripheral  nerve,  produce  exactly  the  same  form  of  paralysis  as  a 
lesion  of  the  nerve  trunk  itself,  biit  the  differential  diagnosis  in  such 
cases  is  usually  not  difficult. 


15° 


DIAGNOSIS. 


3.  The  exact  nature  of  the  mental  symjJtoms  may  sometimes,  though 
it  may  be  confessed  rarely,  give  a  clue  to  the  position  of  the  lesion. — 
(See  page  151.) 

4.  The  presence  of  certain  visceral  derangements. — Tumours  of  the  pons 
Varolii  and  medulla  olilongata  are  more  likely  to  be  attended  with 


r'^lsgr 


/ 


"■55=^ 


Fig.  46. — The  skull-cap  seen  from  above  in  a  case  of  exteeme  disten- 
tion of  the  ventricles,  the  result  of  a  hydatid  tumour  in  the  cerebellum. 
(Copied  from  a  photograph. )  i 

The  letter  T  points  to  one  of  the  ossa  traquetra,  which  were  largely  de- 
veloped in  this  case.  The  dark  shading  between  the  bones  of  the  skull  shows 
the  extent  of  separation  of  the  sutures. 

visceral  derangements  (such  as  polyuria,  glycosuria,  or  even  albumi- 
nuria, derangements  of  the  pulse  and  respiration,  dysphagia,  &c.)  than 
tumours  of  other  parts. 


THE  LOCALISATION  OF  THE  LESION.  151 

5.  The  condition  of  the,  cranium  and  scal'p. — The  presence  of 
localised  depressions,  enlargements,  irregularities,  or  painful  spots  on 
the  surface  of  the  head,  is  in  some  cases  of  importance.  In  some 
cases  of  cancer  and  sarcoma  the  new  growth  makes  its  way  through 
the  bones  of  the  skull.  General  enlargement  of  the  head  is  occa- 
sionally seen  in  children,  and  is  usually  due  to  extensive  ventricular 
dropsy,  which  is,  as  we  have  seen,  most  frequently  associated  with 
subtentorial  tumours.  A  voluminous  tumour  of  one  hemisphere  may 
also  produce  enlargement  of  the  head  in  a  young  child.  In  the 
adult,  after  the  sutures  have  become  firmly  ossified,  they  do  not  of 
course  give  way ;  but  in  young  persons,  separation  of  the  closed 
but  unossified  lines  of  suture  is  by  no  means  uncommon. — (See 
Figs.  45  and  46.) 

Let  us  now  consider  the  symptoms  which  are  produced  by,  and 
which  are  characteristic  of,  tumours  in  special  parts  of  the  intracranial 
contents.  And  in  connection  with  this  part  of  the  subject,  the  local- 
ising symptoms  only  will  be  specially  referred  to,  but  it  must  of  course 
be  understood  that  in  all  cases  "general"  symptoms  of  different 
degrees  of  severity  (headache,  vomiting,  vertigo,  double  optic  neuritis, 
with  or  without  dimness  of  vision,  &c.)  may  be  present. 

Tumours  of  the  Frontal  Lobe. 

Tumours  of  the  frontal  lobe  are  not  uncommon ;  the  nature  and 
severity  of  the  general  symptoms  vary  in  different  cases,  and  are  in 
no  way  characteristic ;  vomiting  is  perhaps  less  frequent,  and  certainly 
as  a  rule  less  severe,  than  in  the  case  of  tumours  which  are  situated 
further  back.  Generalised  epileptiform  convulsions  are  also  perhaps 
less  frequently  met  with.  In  many  cases  the  only  j^os-i^m  symptoms  are 
marked  mental  impairment,  loss  of  memory,  and  want  of  the  power  of 
mental  concentration.  Whether  this  condition  is  a  constant  result  of 
tumours  of  the  frontal  lobe  remains  to  be  seen.  It  has  been  present  in 
all  the  cases  which  have  come  under  my  own  personal  observation,  and 
it  seems  to  have  been  a  noticeable  result  of  destruction  of  the  frontal 
lobes  in  the  lower  animals.  Mental  impairment,  loss  of  memory,  and 
want  of  the  power  of  concentration  are  of  course  frequently  produced 
by  lesions  in  other  parts  of  the  brain,  more  especially  "  diffused " 


15^ 


LOCAL  DLA  GNOSIS. 


lesions.  All  that  we  can  say  is  that  these  symptoms  are  apparently 
more  marked  and  more  frequently  produced  by  a  localised  lesion 
(tumour)  which  involves  the  frontal  lobes,  than  by  a  localised  tumour 
which  involves  other  parts  of  the  brain  tissue. 

In  Figs.  47  and  48,  the  position  of  two  tumours  of  the  frontal 
lobe,  in  which  mental  symptoms  were  very  prominent,  is  represented. 

In  one  of  my  cases  the  head  seemed  to  fall  towards  the  opposite 
side,  apparently  as  the  result  of  loss  of  power  in  the  muscles  of  the 
neck.  This,  too,  is  in  accord  with  Ferrier's  observations.  He  be- 
lieves "  that  this  portion  of  the  brain  is  specially  concerned  in  the 


Fig.  47. — Transverse  vertical  section  through  the  frontal  lobes  in  the 
case  of  Miss  A. ,  showing  the  position  of  the  lesion.     Drawn  from  memory. 

A  points  to  the  lesion  in  the  left  frontal  lobe,  and  5  to  a  portion  of  the 
right  frontal  lobe  affected  by  the  direct  extension  of  the  tumour. 

movements  of  the  head  and  eyes."  He  noticed  that  after  destruction 
of  the  prefrontal  lobes  a  mental  deterioration  which  is  essentially  a 
defect  of  the  faculty  of  attention  is  observed.  He  states,  "  Besides 
the  physiological  symptoms,  such  as  occur,  and  the  descending  degene- 
rations of  the  motor  tracts  associated  with  lesions  of  the  frontal  lobes, 
I  observed  and  recorded  certain  symptoms  indicative  of  mental  de- 
terioration which  have  since  been  confirmed  by  other  physiologists. 
In  my  first  series  of  experiments  (carried  out  without  antiseptics),  I 
noted,  after  removal  of  the  prefrontal  regions,  a  decided  alteration  in 


TUMOURS  OF  THE  FRONTAL  LOBE.  153 

the  animals'  character  and  behaviour,  but  dithcult  to  describe  precisely. 
After  the  operation,  though  they  might  seem  to  one  who  had  not 
compared  their  present  with  their  past,  fairly  up  to  the  average  of 
monkey  intelligence,  they  had  changed  considerably.  Instead  of,  as 
before,  being  actively  interested  in  their  surroundings,  and  curiously 
prying  into  all  that  came  within  the  field  of  their  observation,  they 
remained  apathetic  or  dull,  or  dozed  off  to  sleep,  responding  only  to 
the  sensations  or  impressions  of  the  moment,  or  varying  their  listless- 


FiG.  48. — Longitudinal  section  through  the  brain  in  the  case  of  D.  M., 
showing  the  position  of  the  lesion. 
The  letter  C  points  to  the  tumour. 

ness  with  restless  and  purposeless  wanderings  to  and  fro.  Whilst  not 
absolutely  demented,  they  had  lost  to  all  appearance  the  faculty  of 
attentive  and  intelligent  observation."  ^ 

Tumours  springing  from  the  under  surface  of  the  frontal  lobes, 
which  involve  (either  directly  or  by  the  inflammatory  complications 

^   The  Functions  of  the  Brain,  Second  Edition,  p.  401. 


154  LOCAL  DL A  GNOSIS. 

to  which  they  give  rise)  the  olfactory  bulbs  or  tracts,  or  the  optic 
chiasma,  may  produce  loss  of  the  sense  of  smell  or  temporal 
hemianopsia. 

Tumours  of  tlie  left  frontal  lobe,  which  encroach  upon  or  involve 
the  posterior  third  of  the  inferior  frontal  convolution,  will  in  right- 
handed  persons  probably  be  attended  with  motor  aphasia,  which, 
for  the  reasons  previously  given,  is  usually  incomplete.  Some 
authorities  think  that  the  motor  writing  centre  is  situated  in  the 
posterior  part  of  the  second  left  frontal  convolution ;  and  if  this  is 
so,  tumours  of  the  left  frontal  lobe,  which  encroach  upon  or  involve 
this  portion  of  the  cortex,  should  be  attended  with  motor  agraphia. 
— (See  Fig.  39,  page  116.) 

Tumours  confined  to  the  frontal  lobes  do  not  produce  paralysis 
(except  perhaps  impairment  of  some  of  the  movements  of  the  head 
and  neck,  and  of  the  eyeballs),  and  are  not  attended  with  any  special 
sensory  disturbances. 

Should  the  tumour  extend  backwards,  so  as  to  involve  the  fibres 
passing  from  the  motor  centres  to  the  internal  capsule,  or  the  motor 
portions  of  the  internal  capsule  itself,  intermittent  tremor,  such  as  is 
caused  by  pressure  on  the  motor-conducting  fibres  (see  page  72),  or 
actual  paralysis  of  the  muscles  on  the  opposite  side  of  the  body,  may 
of  course  be  produced.  In  the  Edinhurgh  Medical  Journal  for  January 
1887,  page  616, 1  have  reported  a  case,  in  which  a  cyst  connected  with  a 
glioma  of  the  left  frontal  lobe  was  in  contact  with  the  motor  strands 
of  the  internal  capsule,  and  produced  "pressure  tremor"  and  inter- 
mittent paralysis  in  the  right  arm  and  leg.  In  two  cases  of  tumour 
of  the  frontal  lobe,  I  have  observed  sudden  temporary  loss  of  power 
in  the  arm  and  leg  on  the  opposite  side. 

Tumours  of  the  Motor  Area  {Bolandic  Eegioii). 

Tumours  in  this  situation  are  as  a  rule  more  easily  localised 
than  tumours  in  any  other  part  of  the  cerebral  hemispheres,  for  the 
special  symptoms  which  they  produce — localised  paralyses  and  spasms 
— are  often  most  striking  and  characteristic. 

It  is,  however,  important  to  note  that  even  large  tumours  which 
produce  extensive  destruction  of  the  motor  centres  may  be  entirely 
latent  (so  far  as  localising  symptoms  are  concerned),  provided  that 


TUMOURS  OF  THE  MOTOR  AREA.  155 

tluy  are  of  very  sloiu  growth. — (See  Chapter  I.,  Kgs.  1,  2,  3,  and  4.) 
This  is  more  especially  the  case  when  the  tumour  involves  the  motor 
centres  for  the  face  and  trunk. 

Tumours  involving  limited  portions  of  the  motor  cortex  will  give 
rise  to  localised  and  limited  paralysis  or  spasm  (monoplegia  or 
monospasm),  in  accordance  with  the  function  of  the  special  portion  of 
grey  matter  (centre)  which  they  irritate  or  destroy. 

General  (bilateral)  epileptiform  convulsions  are  often  caused  by 
tumours  in  the  motor  area ;  but  the  spasm  almost  always  begins  in  a 
definite  and  localised  manner,  and  without  loss  of  consciousness ;  in 
short,  the  epileptic  fit  is  preceded  by  a  localised  epileptiform  convul- 
sion of  the  Jacksonian  type  (see  the  case  described  on  page  79.) 

When  the  tumour  involves  the  left  motor  region,  aphasic  symp- 
toms are  often  present. 

A  progressively  advancing  paralysis,  involving  first  one  part  and 
then  another,  is  very  characteristic  of  a  tumour  involving  the  motor 
cortex  or  subcortical  tissue  in  this  region. 

Localised  (cerebral)  paralysis,  wdthout  spasm,  is  more  probably 
due  to  pressure  on,  or  destruction  of,  the  conducting  fibres,  than  to 
involvement  of  the  cortical  grey  matter.  It  may,  however,  be  due  to 
slow  destruction  (without  initial  irritation)  of  a  motor  centre. 

Localised  paralyses  of  this  description  are  readily  enough  distin- 
guished from  the  localised  paralyses  due  to  peripheral  or  nuclear 
lesions,  by  the  fact  that  there  is  no  marked  atrophy  in  the  paralysed 
muscles,  no  "reaction  of  degeneration,"  and  that,  in  most  cases  at 
all  events,  the  deep  reflexes  are  exaggerated  rather  than  diminished 
or  abolished. 

Wliether  destruction  of  the  motor  region  of  the  cortex  is  attended 
with  any  impairment  of  tactile  sensibility,  and  with  loss  of  the 
muscular  sense  in  the  paralysed  parts,  is  a  question  which  requires 
further  investigation.  Ferrier  is  strongly  of  opinion  that  in  such 
cases  there  is  absolutely  no  anaesthesia ;  but  Charlton  Bastian  thinks 
differently,  and  I  have  certainly  seen  some  tactile  loss  in  more  than 
one  case.  It  may,  however,  be  confidently  stated  that  lesions  (tumours), 
which  involve  and  are  limited  to  the  motor  area,  do  not,  so  far  as  we 
at  present  know,  give  rise  to  marked  anaesthesia. 

In  those  cases  in  which  profound  anaesthesia  (hemi-antesthesia)  is 


156  LOCAL  DLAGNOSLS. 

present,  the  lesion  has  in  all  probability  extended  from  the  cortex  into 
the  white  matter,  and  invaded  the  sensory  fibres  of  the  internal  capsule. 

In  their  later  stages,  tumours  of  the  motor  area  may  of  course 
extend  to  and  in\-olve  surrounding  parts.  Aphasic  symptoms — both 
motor  and  sensory — homonymous  hemianopsia,  and  liemi-anpesthesia 
may  be  produced  in  this  manner. 

With  reference  to  the  functions  of  individual  parts  of  the  motor 
area,  see  Terrier's  Functions  of  the  Brain,  and  Figs.  16,  17,  and  18, 
pages  72-74 ;  also  Horsley  and  Schafer's  Paper  in  the  Philosophical 
Transactions,  1888. 

Tumours  of  the  Post- Parietal  Region  and  Occipital  Lohe. 

It  is  now  universally  acknowledged  that  the  function  of  those 
portions  of  tlie  cerebral  hemisphere  which  are  situated  behind  the 
Piolandic  area  (motor  region)  is  sensory;  but  different  observers  are 
not  absolutely  agreed  as  to  the  exact  function  of  the  different  parts  of 
this  extensive  region. 

The  researches  of  Ferrier  seem  to  show  that  the  angular  gyrus 
and  occipital  lobe  are  visual  centres,  and  it  would  appear  that  dis- 
charging lesions  in  this  region  may  produce  flashes  of  light  or  other 
subjective  visual  sensations,  while  destroying  lesions  may  produce 
hemianopsia.  Terrier's  results  with  regard  to  lesions  of  the  angular 
gyrus  are,  as  has  been  pre^'iously  stated,  disputed  by  Schafer  (see 
page  97). 

The  exact  character  of  tlie  hemianopsia  would  appear  to  differ  with 
the  position  of  tiie  lesion.  Tumours  involving  the  back  parts  of  the 
occipital  lobe,  or  the  radiating  visual  fibres  as  they  pass  backwards  to 
this  centre  seem  to  give  rise  to  the  form  of  homonymous  hemi- 
anopsia shown  in  Fig.  23  ;  while  lesions  (tumours)  nearer  the  angular 
gyrus  (perhaps)  produce  a  form  of  homonymous  hemianopsia  in 
which  the  peripheral  parts  of  the  seeing  halves  of  each  field  are 
constricted,  and  which  is  represented  in  Figs.  2-4  and  25. 

Ferrier  found  that,  in  the  monkey,  destruction  of  the  angular  gyrus 
produced  crossed  amblyopia  (blindness  of  the  opposite  eye),  which  was, 
however,  of  quite  temporary  duration.  Whether  the  same  condition 
results  from  lesions  of  the  angular  gyrus  in  man  is  not  yet  deter- 
mined ;  but  in  some  hysterical  cases  (in  which  perhaps  the  functional 


TUMOURS  OF  THE  POST-PARIETAL  REGION.        157 

derangement  involves  this  portion  of  the  cortex)  there  is,  according 
to  Charcot,  crossed  amblyopia  with  some  peripheral  contraction  of  the 
visual  field  in  the  eye  on  the  side  of  the  lesion  {i.e.,  on  the  side 
opposite  to  the  hemi-anaestliesia).  Be  that  as  it  may,  lateral  or  homony- 
mous hemianopsia  seems  to  result  from  "  destroying  "  lesions  in  this 
situation,  and  is  therefore  of  some  localising  value.  The  importance 
of  a  careful  examination  of  the  fields  of  vision  by  means  of  the  peri- 
meter, in  all  cases  in  which  there  is  reason  to  suspect  a  tumour  of 
the  angular  gyrus  or  occipital  lobe,  is  obvious,  and  has  already  been 
insisted  upon. 

Since,  however,  homonymous  hemianopsia  may  also  result  from  a 
lesion  of  the  optic  tract  or  visual  fibres  in  the  internal  capsule,  it  is 
by  no  means  distinctive  of  a  lesion  of  the  occipital  lobe. 

If  the  hemianopsia  is  preceded  by  discharges  (flashes  of  light)  in  the 
parts  of  the  retina,  which  subsequently  become  paralysed,  {i.e..,  blind), 
as  in  the  case  referred  to  on  page  101,  the  condition  is  strictly  analogous 
to  the  ordinary  (motor)  form  of  Jacksonian  epilepsy,  and  a  (discharg- 
ing) lesion  of  the  visual  centre  may  reasonably  be  thought  to  be  present. 

Tumours  involving  the  left  angular  gyrus  may  in  right-handed 
persons  be  expected  to  produce  more  or  less  "  word-blindness." 

In  addition  to  these  visual  defects,  tumours  of  the  occipital  lobe 
and  post-parietal  region  often  produce  impairment  of  the  sense  of 
touch  on  the  opposite  side  of  the  body,  for  they  frequently  involve 
the  conducting  fibres,  which  convey  tactile  impressions,  as  they 
radiate  from  the  posterior  part  of  the  internal  capsule  to  the  tactile 
centre  in  the  cortex.  The  exact  position  of  the  tactile  centre  is  still 
a  disputed  point,  but  the  observations  of  Ferrier  and  Schafer  seem  to 
show  that  it  is  situated  in  the  hippocampal  region  and  gyrus  fornicatus 
(see  page  89).  Whether  the  tactile  sense  is  in  any  way  represented 
in  the  convolutions  of  the  Eolandic  (motor)  area  is  also,  as  we  have 
seen,  a  matter  of  debate. 

Tumours  of  the  post-parietal  region  may  of  course  extend  for- 
wards and  involve  the  motor  centres,  or  downwards  and  inwards,  and 
involve  the  motor-conducting  fibres  as  they  pass  from  the  motor 
centres  to  the  motor  region  of  the  internal  capsule.  Spasms  and 
paralysis  may  therefore  be  present  in  the  later  stages  of  sucli  cases. 

General  epileptiform  convulsions,  preceded  perhaps  by  a  sensory 


15S  LOCAL  DLAGNOSLS. 

(visual)  aura,  and  not  resulting  from  a  localised  motor  discharge  (in 
other  words,  not  preceded  by  ordinary  Jacksonian  epilepsy),  are 
perhaps  more  common  in  cases  of  tumour  of  the  post-parietal  and 
occipital  regions  than  in  tumours  of  the  other  parts  previously 
described  (frontal  lobe  and  motor  area). 

Dr.  Hughlings  Jackson  seems  to  think  that  lesions  of  the  occipital 
lobes,  and  especially  of  the  right  occipital  lobe,  are  attended  with 
more  profound  mental  impairment  than  lesions  of  the  motor  area, 
but  this  opinion  is  doubted  by  some  other  authorities.  My  own 
experience  would  indeed  lead  me  to  suppose  that  the  mental  deterio- 
ration is  greater  when  the  tumour  involves  the  frontal,  than  when  it 
involves  the  occipital  lobes. 

Tumours  of  the  T&m'poro-hi'plunoidal  Lobe 

In  these  cases  there  are  often  no  special  symptoms.  The  centres 
for  hearing,  taste,  and  smell  are  situated  in  the  temporo-sphenoidal 
lobe,  but,  as  has  been  previously  stated,  marked  loss  of  hearing,  taste, 
and  smell  does  not  seem  to  result  from  destruction  of  the  centre  on 
one  side.  It  is  probable,  however,  that  complete  destruction  of  the 
hearing  centre  (and  perhaps  also  of  the  smell  aud  taste  centres)  on 
one  side  is  attended  with  some  degree  of  impairment. 

Lesions  of  the  upper  temporo-sphenoidal  convolution,  on  the  left 
side  (auditory  "  word  centre  "),  in  some  cases  at  all  events,  seem  to 
produce  "  word-blindness." 

Epileptiform  convulsions,  preceded  by  a  noise  in  the  ear,  or  by  a 
peculiar  taste  or  smell,  are  suggestive  of  a  discharging  lesion  of  the 
corresponding  centre  in  the  temporo-sphenoidal  lobe. 

Tumours  which  destroy  the  hippocauipal  region  may  be  expected 
to  produce  hemi-antesthesia,  and  (according  to  Ferrier)  loss  of  the 
muscular  sense  on  the  opposite  side  of  the  body.  Tumours  of  the 
temporo-sphenoidal  lobe,  which  do  not  directly  involve  the  hippo- 
campal  lobule  (the  tactile  centre),  may  interrupt  or  destroy  the  tactile 
conducting  fibres  as  they  pass  to  that  centre. 

In  some  cases  hysterical  symptoms  are  prominent,  but  whether 
this  is  merely  accidental,  or  the  result  of  the  special  position  of  the 
lesion  (in  the  temporo-sphenoidal  lobe),  I  am  unable  to  say. 

Lar"e  tumours  of  the  temporo-sphenoidal  lobe  may  extend  to  and 


TUMOURS  OF  THE  CENTRUM  OVALE.  159 

invade  other  and  adjacent  centres  or  tracts,  and  in  their  later  stages 
may  be  attended  with  spasms,  paralyses,  visual  defects,  motor 
speech  derangements,  &c.,  from  invasion  of  the  motor  area  or  post- 
parietal  regions. 

Tumours  of  the,  Centrum  Ovale. 

The  character  of  the  localising  symptoms  in  these  cases  depends 
upon  the  exact  position  of  the  tumour  and  its  relationship  to  the 
special  fibres  and  tracts  of  which  the  centrum  ovale  is  composed. 
Tumours  of  the  front  part  of  the  centrum  ovale  chiefly  involve  the 
fibres  passing  downwards  from  the  frontal  lobe ;  tumours  of  the  mid- 
region  those  from  the  motor  centres  ;  and  tumours  of  the  posterior 
part  the  fibres  passing  upwards  to  the  sensory  centres  in  the  occipital 
and  temporo- sphenoidal  lobes. 

The  nearer  the  lesion  is  to  the  basal  ganglia  and  internal  capsule 
the  greater  the  risk  of  all  three  sets  of  conducting  fibres  being  involved. 
.  Lesions  in  the  centrum  ovale  will  also,  of  course,  intercept  the 
fibres  which  connect  the  two  hemispheres,  and  different  parts  of  the 
same  hemisphere  with  one  another.  Our  knowledge  of  the  course 
and  functions  of  these  connecting  (commissural)  fibres  is,  as  yet,  so 
entirely  indefinite,  that  it  is  impossible  to  make  any  statement  as  to 
the  special  symptoms  which  result  from  their  destruction.  It  mav, 
however,  be  stated  that  tumours  of  the  left  hemisphere,  which  destroy 
the  fibres  connecting  the  sensory  with  the  motor  speech  centres 
(the  exact  course  of  which  is  not  yet  definitely  determined),  may  be 
expected  to  produce  aphasic  symptoms. 

Tumours  of  the  centrum  ovale,  which  involve  the  cortical  grey 
matter,  may  act  as  sources  of  irritation  and  discharge,  and  may 
produce  spasms,  convulsions,  or  sensory  phenomena,  but  in  most  of 
the  cases  of  this  kind,  which  have  come  under  my  own  notice,  irritati\'e 
symptoms  have  not  been  prominent. 

The  absence  of  irritative  symptoms  in  the  cases  to  which  I  refer  may 
have  been  due  to  the  fact  that  the  tumours  were  mostly  gliomata, 
which  are,  I  think,  less  apt  to  excite  discharge  than  some  other  forms 
of  new  growth;  and  to  the  circumstance  that  many  of  the  conductino- 
fibres,  passing  from  the  cortical  centres  in  contact  with  the  new 
growth,  were  destroyed  before  the  centres  themselves  were  irritated. 


i6o  LOCAL  DIAGNOSLS. 

TuDWurs  of  the  Corpus  Ccdlosum. 

Tumours  in  this  situation  are  not  very  common.  They  are  usually 
gliomata  or  sarcomata,  which  steadily  progress  until  the  new  growth 
may  make  its  way  into  the  centrum  ovale  of  each  hemisphere.  The 
symptom  which  is  most  characteristic  of  a  tumour  in  this  situation  is 
a  gradually  developing  paralysis  (more  or  less  complete  hemiplegia), 
hrst  on  one  side  and  then  on  the  other.  Should  the  tumour  invade 
the  posterior  part  of  the  centrum  ovale  rather  than  the  anterior,  there 
might  be  a  gi-adually  advancing  and  bilateral  hemiansesthesia  instead 
of  motor  paralysis. 

There  is,  in  addition,  in  some  cases,  marked  mental  impairment, 
and  some  affection  of  speech.  Dr.  Bristowe,  who  has  written  the 
most  complete  account  of  tumours  of  tlie  corpus  callosum  with  which 
I  am  acquainted,  sums  up  tlieir  chief  characters  as  follows  : — 

"  1st.  Their  ingravescent  character — a  character  which  they  possess 
in  common  with  other  cases  of  cerebral  tumour ;  2ncl  The  gradual 
coming  on  of  hemiplegia,  for  the  most  part  resembling  in  its  distri- 
bution the  paralytic  symptoms  usually  attending  hemorrhage  into 
one  of  the  hemispheres,  or  softening  due  to  embolism  ;  ord.  The  asso- 
ciation with  the  paralysis  of  one  side  of  vague  hemiplegic  symptoms 
of  the  othei? ;  4:th.  The  supervention  of  stupidity,  associated  for  the 
most  part  with  extreme  drowsiness,  a  puzzled  inquiring  look  when 
awake,  a  difticulty  of  getting  food  down  the  throat,  and  cessation  of 
speech.  I  say  a  difhculty  of  getting  food  out  of  the  mouth,  rather 
than  paralysis  of  the  mouth  and  throat,  and  I  say  a  cessation  of 
speech  rather  than  aphasia  or  loss  of  articulating  power,  because  it 
seems  to  me,  in  watching  the  cases,  that  these  phenomena  were  due 
mainly  to  stupidity  and  irresistible  tendency  to  sleep,  and  not  de- 
finitely to  paralysis  or  affection  of  the  centres  for  speech;  5th.  The 
absence  of  implication  of  the  oculo-motor  nerves,  and  of  direct 
implication  of  other  cerebral  nerves ;  and  lastly,  death  from  coma." 
And  ao-ain — "  Indeed  I  take  it  that  the  symptoms  the  patients  pre- 
sented were  due  chiefly,  if  not  altogether,  to  the  extension  of  the 
disease  into  the  hemispheres  and  to  the  diffused  pressure  on  important 
parts  caused  by  the  great  collective  bulk  of  the  tumour,  as  evidenced 
by  the  extensive  flattening  of  the  surface  of  the  hemispheres,  and  the 


TUMOURS  OF  THE  BASE.  i6i 

singular  absence  of  both  subarachnoid  and  ventricular  fluid.  Assum- 
ing this  explanation  to  be  correct,  the  progress  of  a  case  of  the  disease 
I  have  been  describing  should  be  as  follows : — -first,  the  occurrence  of 
headache  and  other  somewhat  vague  symptoms  of  progressive  cerebral 
disease ;  second,  the  gradual  onset  of  more  or  less  well  -  marked 
hemiplegia ;  third,  the  appearance,  in  a  greater  or  less  degree,  of 
similar  symptoms  on  the  opposite  side  of  the  body  ;  fourth,  the 
coming  on  of  dementia,  with  drowsiness,  loss  of  speech,  difficulty  in 
swallowing,  and  want  of  control  over  the  rectum  and  Ijladder."  ^ 

Tumours  of  the  Base. 

The  new  growths  which  most  frequently  occur  at  the  base  of  the 
brain  are  —  syphilitic  gummata ;  tumours  (simple  enlargement  or 
various  forms  of  new  growths)  of  the  pituitary  body;  aneurisms 
springing  from  the  arteries  forming  the  circle  of  Willis  ;  and  cancerous 
and  sarcomatous  tumours  growing  from  the  bones  at  the  base  of  the 
skull,  or  from  the  dura  mater. 

The  character  of  the  symptoms  depends  upon  the  exact  position 
of  the  new  growth ;  but  the  most  important  localising  symptoms  are 
due  to  pressure  on,  or  involvement  of,  one  or  more  of  the  cranial  nerves, 
on  one  or  both  sides.  When  several  nerves  are  implicated,  the  exact 
position  of  the  tumour  can  be  more  accurately  determined  than  when 
only  one  is  involved,  for  implication  of  several  nerves  means  a  lesion 
at  the  point  where  they  come  in  contact  or  juxtaposition.  Paralysis, 
for  example,  of  the  parts  supplied  by  the  third,  fourth,  and  sixth 
nerves  on  one  side,  with  unilateral  optic  neuritis  or  optic  atrophy, 
means  a  lesion  either  in  the  back  of  the  orbit  or  involvement  of  the 
nerves  as  they  pass  into  the  orbital  fissure  and  optic  foramen  ;  while 
paralysis  of  the  external  rectus  may  be  produced  by  many  different 
lesions,  involving  the  sixth  nerve  in  its  long  and  exposed  course. 

Tumours  of  the  anterior  region  of  the  base.  —  Tumours  of  the 
pituitary  body,  when  of  large  size,  such  as  that  represented  in  Figs. 
49  and  50,  may  be  attended  with  general  symptoms  (headache,  vomit- 
ing, optic  neuritis,  gradual  and  progressive  dementia) ;  but  in  some 
cases  the  general  symptoms  are  little  marked.  Aneurisms  in  this 
situation  are  often  "  latent "  until  the  final  rupture  occurs ;  for  the 

^  Bruin,  vol.  vii.,  pp.  .318  and  319. 
L 


l62 


LOCAL  DLAGNOSLS. 


majority  of  aueurisms  at  the  base  of  the  brain  are  of  small  size.  It  is 
altogether  exceptional  for  them  to  attain  to  the  extraordinary  dimen- 
sions shown  in  Figs  51,  52,  53,  54,  and  55. 


Fig.  49. — Autotype  reproduction  of  a  photograph  of  the  base  of  the  brain, 
showing  a  tumour  of  the  pituitary  body.  (Considerably  less  than  the 
actual  size.) 

A  brief  record  of  the  case  will  be  found  in  Dr.  Berry's  Subjective 
Symptoms  in  Eye  Disease,  page  111,  There  was  very  marked  temporal 
hemianopsia,  the  temporal  halves  of  each  field  being  absolutely  blind. 

The  most  important  localising  symptom  of  tumours  in  the  posi- 
tion of  the  pituitary  body  is  probably  temporal  hemianopsia,  the 
result  of  pressure  on  the  central  part  of  the  optic  chiasma.  It  is 
important  to  remember  that,  in  cases  of  this  description,  optic  neuritis 
may  be  absent,  and  that  after  the  hemianopsia  has  lasted  for  a  longer 


TUMOURS  OF  THE  BASE. 


163 


or  a  shorter  time,  optic  atrophy  and  total  blindness  (not  preceded  by 
papillitis)  may  be  developed. 

In  some  cases  the  defect  of  vision  varies  in  extent  from  time  to 
time,  being  better  one  day  and  worse  the  next.  Such  alterations  are 
suggestive  of  fluid  pressure,  such  as  would  be  caused  by  an  aneurism 
or  cyst,  the  tension  of  which  was  variable. 

The  same  alterations  in  the  extent  of  the  visual  defect  have,  how- 
ever, been  noticed  as  the  result  of  syphilitic  lesions  (gummata)  in 
this  situation. 

Tumours  in  the  region  of  the  pituitary  body  may  involve  one  or 
both  olfactory  tracts,  and  produce  loss  of  smell  in  one  or  both  nostrils. 


Fig.  50. — Transverse  vertical  section  through  the  brain  in  the  case 
represented  in  Fig.  49,  sho\ving  the  relationship  of  the  tumour  (/)  to  the 
adjacent  parts.  (Facsimile  representation  of  a  section  of  the  brain  prepared 
by  the  author's  "ready  method.") 

The  tumour  is  growing  upwards  towards  the  ventricles  ;  and  has  pro- 
duced considerable  distortion  of  the  parts  with  which  it  is  in  contact. 

The  third,  fourth,  and  sixth  nerves  on  one  or  both  sides  may  also 
be  implicated. 

Tumours  of  large  size  (such  as  those  represented  in  Figs.  49  to 
55)  may  press  upon  the  crura  cerebri,  and  make  their  way  upwards 
towards  the  ventricles.  Dementia  and  hebetude  may  in  such  cases  be 
very  great.     Paralysis,  usually  incomplete,  in  the  face  or  limbs  on  one 


1 64  LOCAL  DLAGNOSLS. 

or  both  sides  may  also  result  from  the  pressure  of  tlie  tumour  on  the 

motor  tracts. 

Tumours  of  the  pituitary  body  are  in  many  instances  attended  with 


Yi(i  51.— Autotj^e  reproduction  of  a  photograph  of  the  base  of  the 
brain  in  the  case  of  C.  F.,  showing  the  aneurism  (C)  projecting  down^-arda 
in  the  interpeduncular  space.     (Considerably  less  than  the  actual  size  of  the 

^""^  The  St  hemisphere  of  the  brain  and  the  left  lateral  lobe  of  the  cere- 
bellum are  smaUer  than  the  corresponding  parts  on  the  opposite  side. 
Whether  this  difference  was  present  during  life  it  is  difficult  to  decide,  in 
consequence  of  the  division  of  the  corpus  caUosum  and  the  long  preservation 
in  spirit  the  relative  position  and  relationship  of  the  parts  were  somewhat 
altered  Before  this  photosuraph  was  taken  the  frontal  lobes  were  hxed  in 
position  by  means  of  a  thinVece  of  string.  The  aneurism  does  not  project 
do^vnwards  in  the  hardened  brain  (photograph)  so  far  as  it  appears  to  have 
done  in  the  recent  state.  The  letter  A  points  to  the  right,  an*  the  letter  B 
to  the  left  optic  nerve,  which  are  t^^•isted  backwards.  Immediately  above 
the  part  of  the  aneurism  to  which  the  letter  C  points,  the  left.mternal  carotid 
artery,  with  a  clot  projecting  from  its  cavity,  is  situated. 


TUMOURS  OF  THE  BASE.  165 

an  excessive  development  of  the  subcutaneous  fat,  and  in  some  cases 
with  the  presence  of  sugar  in  the  urine,  or  with  simple  polyuria 
(diabetes  insipidus). 

Whether  these  symptoms  are  due  to  the  fact  that  the  pituitary 
body  itself  is  diseased,  or  whether,  as  seems  more  likely,  to  the 
secondary  results  which  tumours  in  this  situation  produce  in  the  sur- 
rounding cerebral  tissue,  has  not  yet  been  decided. 


Fig.  52. — Autotype  reproduction  of  a  photograph  of  the  brain  in  the 
case  of  C.  F. ,  showing  the  aneurism  projecting  upwards  into  the  third  and 
lateral  ventricles.    (Considerably  less  than  the  actual  size  of  the  preparation.) 

The  corpus  callosum  has  been  divided  and  the  hemisphere  separated  so 
as  to  fully  expose  the  tumour  ;  the  upper  surface  of  the  cerebellum  has  also 
been  partly  divided  in  an  antero-posterior  direction.  The  letter  A  points  to 
the  aneurism  ;  B,  to  the  right  side  of  the  upper  surface  of  the  cerebellum. 

Possibly,  as  Eosenthal  has  suggested,  the  diabetes,  which  is  some- 
times present,  may  be  the  result  of  secondary  changes  produced  in 


t66 


LOCAL  DLA GNOSIS. 


the  grey  matter  of  the  floor  of  the  fourth  ventricle.  He  supposes  that 
the  pressure  of  the  tumour  first  produces  irritation  of  the  grey  matter 
lining  the  third  ventricle,  and  that  this  irritation  travels  along  the 
grey  matter  which  connects  the  third  and  the  fourth  ventricle,  and 
produces  secondary  changes   in  the   latter.     "  According,"   he  says, 


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TUMOURS  OF  THE  BASE. 


167 


urine  (from  lesion  of  the  centre  of  the  vascular  nerves  of  the 
kidney  according  to  Schiff).  Tumours  of  this  region  may  also  pro- 
duce glycosuria.  If  we  consider,  in  addition,  that  the  tuber  cinereum 
is  found  in  the  immediate  neighbourhood  of,  and  in  advance  of  the 
pituitary  gland,  and  that  the  infundibulum  merely  represents  a  pro- 


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longation  of  the  grey  substance  of  the  third  ventricle,  and  by  continuity 
of  the  fourth  ventricle  into  the  medulla  oblongata,  we  may  admit  that 
tumours  of  the  pituitary  region,  by  an  increase  of  pressure,  may  give 
rise  to  a  paralysis  of  the  medullary  centres  of  hepatic  innervation, 
and  to  consequent  hypersemia  of  the  liver,  resulting  in  diabetes  ?"  ^ 

^  Diseases  of  the  Nervous  System,  American  translation,  p.  120. 


i68 


LOCAL  D  LAG  NO  SIS. 


Probably  some  of  tlie  symptoms  which  result  from  tumours  in  the 
region  of  tlie  pituitary  body  are  due  to  the  pressure  of  the  tumour  on 
the  great  vessels  at  the  base  of  the  brain  (branches  of  the  circle  of 
Willis),  and  to  the  alterations  in  the  nutrition  of  the  cerebral  tissues 
which  may  result  therefrom. 

Syphilitic  gummata  are  very  common  in  the  neighbourhood  of  the 
interpeduncular  space.  The  general  symptoms  to  which  they  give 
rise  are  usually  ^'ery  marked.  The  special  localising  symptoms  are 
due  either  to  involvement  of  the  nerves  (such  as  the  third),  to  asso- 


FiG.  55.- -Autotype  reproduction  of  a  photograph  of  an  immense  in- 
tracranial aneurism  of  the  right  internal  carotid  artery.  (Actual  size  after 
long  preservation  in  spirit. ) 

ciated  arterial  disease  (with  resulting  softening  of  the  cerebral  tissue, 
sometimes  at  a  considerable  distance  from  the  seat  of  the  primary 
lesion),  or  to  pressure  and  involvement  of  adjacent  parts,  such  as  the 
crus  cerebri.  Lesions  in  this  situation  may  therefore  produce  that 
form  of  alternate  hemiplegia,  in  whicli  the  muscles  supplied  by  the 
third  nerve  are  paralysed  on  the  same,  and  those  of  face,  arm,  and  leg 
on  the  opposite  side  of  the  body,  in  two  ways,  ^^z.,  (1.)  l3y  involving 


TUMOURS  OF  THE  BASE.  169 

the  trunk  of  the  third  nerve  and  the  motor  tract  for  the  face,  arm, 
and  leg,  in  the  crus  cerebri ;  or  (2.)  by  involving  the  trunk  of  the  third 
nerve  and  the  middle  cerebral  artery  (and  producing  softening  of  the 
motor  tract  in  the  higher  parts  of  the  cerebral  hemisphere). 

The  mode  of  onset  of  the  paralysis  may  be  different  in  the  two 
cases.  In  the  latter  case  the  paralysis  of  the  eye  muscles  on  the 
same  side,  and  of  the  face  and  the  limbs  on  the  opposite  side,  are  not, 
as  a  rule,  developed  so  simultaneously  as  in  the  former. 

The  sudden  occurrence  of  this  form  of  alternate  hemiplegia, 
therefore,  indicates  a  lesion  of  the  crus  cerebri. 

Paralysis  of  the  muscles  supplied  by  the  third  nerve,  followed, 
after  a  longer  or  a  shorter  interval,  by  hemiplegia  on  the  opposite 
side,  may  be  due  to  a  gumma  at  the  base  involving  the  third  nerve 
and  middle  cerebral  artery.  A  paralysis  of  the  muscles  supplied  by 
the  third  nerve,  closely  followed  by  a  slowly  developing  paralysis  of 
the  face,  arm,  and  leg  on  the  opposite  side,  is  probably  due  to  a  lesion 
at  the  base,  involving  the  trunk  of  the  third  nerve,  and  then  pressing 
upon  and  invading  the  crus  cerebri. 

Syphilitic  gummata,  or  other  tumours  in  the  region  of  the  inter- 
peduncular space,  may  invade  one  optic  tract,  but  in  many  cases  the 
chiasma  and  one  or  both  optic  tracts,  or  the  chiasma  and  one  or 
both  optic  nerves,  are  involved. 

Tvmiours  of  the  middle  region  of  the  hase. — The  most  characteristic 
symptoms  suggestive  of  a  tumour  in  the  middle  fossa  are  those  which 
are  due  to  implication  of  the  trunk  of  the  fifth  nerve  or  the  Gasserian 
ganglion,  viz.,  neuralgic  pains  in  cdl  the  areas  of  distribution  of  the 
nerve,  or  anaesthesia  of  the  same  parts ;  spasmodic  contraction  or 
rigidity,  but  much  more  frequently  paralysis,  of  the  masseter  and 
temporal  muscles  ;  and,  in  some  cases,  trophic  alterations  in  the  eye- 
ball— inflammation  and  suppuration  and  ulceration  of  the  cornea. 

The  trunk  of  the  seventh  and  eighth  nerves  (auditory  and  labyrin- 
thine portions)  may  also  be  involved,  with  resulting  facial  paralysis, 
deafness,  or  giddiness. 

The  third,  fourth,  and  sixth  nerves,  the  optic  tracts,  crus  cerebri, 
and  the  other  parts,  which  are  apt  to  be  involved  by  tumours  in  the 
region  of  the  pituitary  body  or  interpeduncular  space,  may  also,  of 
course,  be  implicated. 


ryo  LOCAL  DLAGNOSLS. 

Tumours  of  the  'posterior  region  of  the  base. — Tumours  of  the 
posterior  fossa,  which  are  situated  laterally,  are  apt  to  involve  the 
trunk  of  the  fifth  nerve  at  its  origin  from  the  pons,  and  so  to  produce 
neuralgia  or  anaesthesia  in  its  area  of  distribution,  spasms  or  paralysis 
of  the  masseter  and  temporal  muscles,  and  rarely  (much  less 
frequently  than  when  the  Gasserian  ganglion  is  involved)  trophic 
alterations  in  the  eyeball.  Tumours  in  this  situation  are  also  apt  to 
involve  the  seventh  (facial),  eighth  (auditory  and  labyrinthine),  ninth, 
(glosso-pharyngeal),  tenth  (pneumo-gastric),  eleventh  (intracranial 
portion  of  the  spinal  accessory),  and  twelfth  (hypoglossal)  nerves,  and 
therefore  to  be  attended  with  symptoms  suggestive  of  a  lesion  of  the 
pons  Varolii  or  medulla  oblongata. 

Tumours  of  the  posterior  fossa,  which  are  centrally  situated, 
may  involve  one  or  both  sixth  nerves,  and,  by  pressing  upon  the 
anterior  pyramids  of  the  medulla  oblongata,  are  more  apt  to  produce 
motor  symptoms  in  the  limbs  than  those  tumours  of  the  posterior 
fossa,  wliich  are  more  laterally  situated. 

The  differential  diagnosis  of  tumours  within  the  pons  Varolii  or 
medulla  oblongata,  and  of  tumours  at  the  base,  pressing  upon  the 
pons  or  medulla  from  without,  is  not  always  possible.  In  the  latter 
case  the  cranial  nerves  are  more  frequently  involved  before  the 
paralysis  or  aneesthesia  in  the  arms  and  legs  is  established.  The 
same  condition  of  matters  may,  however,  result  from  a  tumour 
within  the  pons.  Implication  of  several  nerve  trunks  (in  the 
posterior  fossa)  without  limb  paralysis  is,  however,  strongly  in  favour 
of  a  lesion  at  the  base,  outside  (rather  than  inside)  the  pons  Varolii  or 
medulla  oblongata.  A  small  tumour  outside  the  pons  might  involve 
the  trunk  of  the  hypoglossal  or  ninth  nerve  on  the  same  side,  and  the 
pyramidal  tract,  proceeding  to  the  opposite  arm  and  leg.  It  will  be 
observed  that  in  this  form  of  alternate  hemiplegia  the  face  may  not 
be  affected,  for  the  lesion  is  situated  below  tlie  point  of  exit  of  the 
facial  (seventh)  nerve. 

The  manner,  too  (the  sequence),  in  which  the  different  nerves  are 
involved  is  of  importance,  for  nerves,  which  on  the  surface  or  at  the 
base  of  the  brain  are  situated  closely  together,  often  diverge  within 
the  pons  or  medulla  in  making  their  way  to  or  from  their  respective 
centres  (nerve  nuclei)  of  deep  origin.     At  the    base  of  the  brain 


TUMOURS  OF  THE  BASAL  GANGLIA.  lyi 

(outside  the  pons)  the  seventh  and  eighth  nerves  are,  for  example,  so 
closely  placed  together  that  it  is  almost  impossible  for  a  tumour  to 
press  upon  and  involve  one  without  also  implicating  the  other ;  but 
within  the  pons,  a  small  lesion  may  easily  do  so. 

Tumours  of  the  Basal  Ganglia. 

New  growths  which  invade  the  basal  ganglia  are  rarely  limited  to 
these  structures,  but  usually  involve  the  internal  capsule  or  other 
adjacent  parts.     Even  in  those  cases  in  which  (as  in  that  represented 


Fig.  56. — Autotype  representation  of  a  transverse  vertical  section 
through  the  brain  in  a  case  of  secondary  cancer,  showing  a  cancerous  nodule 
{M)  in  the  position  of  the  lenticular  nucleus,  which  was  in  fact  completely 
destroyed  by  the  new  growth.     (Reduced  from  a  photograph. ) 

in  Fig.  56)  a  nodule  of  new  growth  is  limited  to  one  or  other  of  the 
basal  ganglia,  other  nodules  are  often  present  in  other  parts  of  the 
intracranial  nerve  centres  ;  the  clinical  picture  is  consequently  com- 
plicated, and  it  is  difficult  or  impossible  to  determine  the  symptoms 
which  are  due  to  the  lesion  of  the  ganglia  themselves. 

But,  notwithstanding  these  difficulties,  it  would  appear  (more 
especially  from  a  study  of  the  effects  of  the  hsemorrhagic  extravasa- 
tions  and   softenings,  which  are  much  more  frequently  limited   to 


172  LOCAL  DIAGNOSIS. 

the  basal  ganglia  tlian  new  growths)  that  destruction  of  these 
structures  is  not  attended  with  symptoms  of  a  striking  or  per- 
manent character. 

The  localising  symptoms  which  new  growths  involving  the  basal 
ganglia  do  produce,  seem  to  be  for  the  most  part  due  to  pressure  on, 
or  involvement  of,  the  motor  and  sensory  fibres  of  the  adjacent  in- 
ternal capsule,  and  in  some  cases  of  the  optic  tract.  They  consist  of 
hemiplegia  and  hemi-aneesthesia  on  the  opposite  side  of  the  body, 
and  of  homonymous  hemianopsia.  It  is  of  course  theoretically  pos- 
sible, though  practically  unlikely,  that  a  tumour  originating  in  one 
or  other  of  the  basal  ganglia  might  involve,  for  a  time  at  least,  the 
bundles  of  fibres  for  the  face,  arm,  or  leg  individually,  and  might 
therefore  produce  a  monoplegia  or  imperfect  hemiplegia,  which,  with 
the  development  and  increase  in  the  size  of  the  tumour,  would  become 
more  and  more  complete. 

TurnoiLTS  of  the  coijjus  striatum  {nucleus  caudatus  and  lentindar 
nudeiLs). — So  far  as  can  be  ascertained  from  the  observation  of  disease 
in  man,  complete  destruction  of  the  nucleus  caudatus  and  lenticular 
nucleus  is  unattended  by  any  characteristic  symptoms,  provided 
that  the  adjacent  strands  of  the  internal  capsule  are  not  implicated. 

Ferrier  sums  up  our  knowledge  on  this  point  in  the  following 
T^vords — "  As  a  rule  the  lesions  of  disease  are  more  or  less  indefinite,  but 
the  careful  investigation  of  Charcot  and  others  have  established  that, 
though  lesions  of  the  nucleus  caudatus  or  lenticular  nucleus  appear  to 
cause  hemiplegia,  in  all  respects  similar  to  that  caused  by  lesions 
of  the  anterior  two-thirds  of  the  internal  capsule,  or  of  the  cortical 
centres  themselves,  yet  the  hemiplegia  depending  on  lesions  Kmited 
to  the  grey  matter  of  the  striate  nuclei  is  of  a  transitory  character, 
and  may  entirely  disappear  even  while  the  lesion  remains." 

I  have  myself  reported  a  case  of  multiple  scrofulous  timioui's, 
in  which  almost  the  whole  of  the  nucleus  caudatus  on  the  left  side 
was  destroyed  by  a  nodule  of  new  growth,  and  in  which  there 
was  no  paralysis,^  and  another  case  in  which  the  lenticular  nucleus 
was  completely  destroyed,  and  in  which  paralysis  could  not  be 
detected  during  life.- 

*  Edinburgh  Medical  Jonrual,  February  1879,  p.  697. 
2  Brain,  January  1888,  p.  503. 


TUMOURS  OF  THE  CORPUS  STRIATUM.  173 

Whether  irritative  lesions  of  the  corpus  striatum  produce  any 
characteristic  symptoms  has  yet  to  be  determined.  Terrier  finds  that 
"  electrical  irritation  of  the  intra- ventricular  portion  of  the  nucleus  of 
the  corpus  striatum  causes  tonic  contraction  of  the  whole  of  the 
muscles  on  the  opposite  side,  resulting  in  a  condition  of  pleurostho- 
tonus,  in  which  the  position  assumed  is  that  of  equilibrium  between 
the  flexors  and  extensors,"  and,  with  good  reason  as  it  seems  to  me, 
he  thinks  that  these  spasms  are  due  to  irritation  of  the  grey  matter 
of  the  ganglion  itself,  rather  than  to  irritation  of  the  adjacent  fibres  of 
the  internal  capsule. 

Nothnagel  found  that  irritation  (mechanical  and  chemical)  of  a 
localised  spot  in  the  head  of  the  corpus  striatum  (nucleus  caudatus) 
produced  an  irresistible  tendency  to  run  or  jump,  which  movements 
continued  until  the  animal  became  exhausted ;  the  portion  of  grey 
matter  which  was  irritated  in  these  experiments  he  has  consequently 
termed  the  nucleus  cursarius. 

Destruction  of  the  lenticular  nucleus  by  the  same  means  (injec- 
tions of  chromic  acid)  was  found  by  Nothnagel  to  produce  marked 
disturbances,  viz.,  outward  deviation  of  the  opposite  fore-leg,  and  in- 
ward deviation  of  the  hind  leg  on  the  same  side,  bending  of  the  verte- 
bral column  towards  the  side  of  the  lesion,  and  some  dorsal  curvature 
due  to  paralysis  of  the  trunk  muscles.  "When  the  lenticular  nuclei 
were  destroyed  on  both  sides  there  was  no  deviation  of  the  limbs  nor 
distortion  of  the  trunk.  The  animals  maintained  their  normal  atti- 
tude, but  remained  quite  immoveable  and  apathetic,  like  animals 
deprived  of  their  cerebral  hemispheres.  They  allowed  their  limbs 
to  be  withdrawn  or  placed  in  any  abnormal  position  without  resist- 
ance ;  but  if  the  tail  was  pinched,  the  animal  would  make  one  or 
two  leaps  forward,  and  again  relapse  into  its  apathetic  immobility."  ^ 

Ferrier  seems  to  doubt  the  value  of  these  observations,  and  to 
think  that  the  results  which  Nothnagel  obtained  may  have  been  due 
to  lesions  of  the  adjacent  fibres  of  the  internal  capsule.  - 

Tumours  of  the  optic  thalamus  seem  in  some  cases  to  produce  dis- 
turbances of  vision.  Some  writers  state  that  lesions  limited  to  the 
optic  thalamus  may  be  attended  with  homonymous  hemianopsia,  but 

^  Quoted  from  Ferrier,  Functions  of  the  Brain,  Second  Edition,  p.  ill. 
■^  Rid.,  y).  416,  sect,  8. 


174  LOCAL  DLAGNOSLS. 

in  most  cases  of  this  kind  the  visual  defect  was  in  all  probability  due 
either  to  involvement  of  the  external  geniculate  body,  or  to  pressure 
upon  the  optic  tract. 

In  athetosis  and  post-heniiplegic  chorea  the  lesion  is  frequently 
situated  in  the  optic  thalamus,  and  it  is  conceivable  that  these  symp- 
toms might  therefore  be  produced  by  a  tumour  in  this  situation. 

Besides  the  ordinar}'  form  of  hemiplegia  and  hemi-antesthesia, 
which  lesions  (tumours)  of  the  optic  thalamus  may  produce  by  in- 
volving, or  pressing  upon,  the  adjacent  fibres  of  the  internal  capsule, 
it  is  possiljle  that  a  tumour  in  this  situation  might  produce  the  form 
of  alternate  hemiplegia  which  is  usually  due  to  a  lesion  of  the  crus 
cerebri,  in  which  the  muscles  supplied  by  the  third  nerve  are  paralysed 
0)1  the  same  side  as  the  lesion,  while  the  muscles  of  the  face,  arm,  and 
leg  are  involved  on  the  opposite  side. 

TuvwVjTS  of  the  Pons  Varolii,  Corpora  Qicadrigemina,  ami  Pineal  GlaTid. 

Small  tumours  situated  in  the  middle  of  the  pons  Varolii,  and 
those  new  growths  which  do  not  involve  the  great  conducting  (pyra- 
midal) tracts,  or  the  nerves  arising  from  the  pons  (the  nerve  roots  or 
nerve  nuclei),  may,  for  a  time  at  all  events,  be  unattended  by  any 
characteristic  symptoms. 

General  symptoms  (headache,  vomiting,  and  optic  neuritis)  are 
usually  present,  but  by  no  means  always  prominent. 

In  most  cases  of  tumour  of  the  pons  Varolii  there  are,  however, 
well-marked  localising  symptoms,  the  exact  character  of  which  varies 
in  different  cases,  and  depends  upon  the  special  part  of  the  pons  in 
which  the  tumour  is  situated. 

These  symptoms  consist  of — (1)  paralysis  and  anaesthesia  of  the 
face,  limbs,  and  trunk,  the  result  of  involvement  of  the  fibres  of  the 
pyramidal  tracts  as  they  pass  through  the  pons  ;  and  (2)  paralysis  or 
ansesthesia  due  to  implication  of  the  cranial  nerves  which  spring  from 
the  pons,  or  of  their  root-fibres,  nerve-nuclei,  or  connecting  fibres 
(third,  fourth,  fifth,  sixth,  and  seventh  nerves). 

The  paralysis  and  anjesthesia  may  be  on  one  or  both  sides  of 
the  body. 

Tumours  which  implicate  the  pyramidal  tract  on  one  side,  in  the 


TUMOURS  OF  THE  PONS  VAROLII. 


175 


upper  third  of  the  pons  {i.e.,  above  the  point  at  which  the  fibres  of  the 
facial  nerve  leave  the  pyramidal  tract  to  decussate  and  pass  to  their 
nerve  nucleus  on  the  opposite  side),  produce  ordinary  hemiplegia,  %.&., 
paralysis  of  the  face,  arm,  and  leg,  on  the  opposite  side  (see  6,  Fig.  57). 


fm 


Fig.  57. — Diagram  showing  tlie  distribution  of  the  paralysis  which  may 
result  from  lesions  in  the  upper  and  lower  parts  of  the  pons  Varolii. 

The  letters  F,  Ay  L  point  to  the  motor  tracts  for  the  left  side  of  the 
face,  arm,  and  leg,  as  they  enter  the  right  side  of  the  pons  Varolii  (P)  in 
their  passage  from  the  right  hemisphere  of  the  brain.  (Compare  with  Fig. 
U,  p.  69.) 

A  lesion  in  the  upper  third  of  the  right  half  of  the  pons,  in  the  position  of 
6,  will  cause  paralysis  of  the  face,  arm,  and  leg  on  the  opposite  (left)  side — 
ordinary  hemiplegia. 

A  lesion  in  the  lower  third  of  the  right  half  of  the  pons,  in  the  position 
of  7,  will  cause  that  form  of  alternate  hemiplegia  in  which  the  face  is  in- 
volved on  the  same  (right),  and  the  arm  and  leg  on  the  opposite  (left)  side. 

If  the  sensory  fibres  of  the  pyramidal  tract  are  at  the  same  time 
involved,  hemi-anaesthesia,  involving  the  face,  arm,  and  leg  on  the 
opposite  side,  is  also  present. 

Tumours  in  this  situation  (in  the  lateral  half  of  the  upper  third 
of  the  pons)  may  also  involve  the  fibres  or  nerve  nuclei  of  the  third 
or  fourth  nerves  on  the  same  side, — in  short  may  produce  the  form  of 
alternate  hemiplegia  which  is  so  suggestive  of  a  lesion  of  the 
crus  cerebri. 


Tumours  at  the  top  of  the  pons  Varolii,  and  tumours  involving  the 
corpora  quadrigemina,  are  comparatively  rare.  In  addition  to  the 
general  symptoms  suggestive  of  an  intracranial  tumour  which  are 


176  LOCAL  DL A  GNOSIS. 

usually  present,  the  special  symptoms  which  we  would  expect  a 
lesion  in  this  situation  to  produce,  are  paralysis  of  the  ocular  muscles 
supplied  by  tlie  third  and  fourth  nerves,  disorders  of  co-ordination 
and  inability  to  maintain  the  equilibrium,  tonic  spasmodic  contrac- 
tions of  the  muscles  of  the  limbs  and  trunk,  and  perhaps  (when 
the  anterior  tubercles  of  the  corpora  quadrigemina  are  involved) 
some  disorders  of  sight.  Terrier  concludes,  as  the  results  of  his  ex- 
periments, that  ■''  the  optic  lobes  are  the  centres  of  correlation  between 
retinal  impressions  and  oculo-motor  reactions,"  and  that,  "  whatever 
may  be  their  exact  position,  we  are  justified  in  assuming  that  there 
are,  in  the  region  of  the  corpora  quadrigemina,  fibres  of  connec- 
tion between  the  optic  tracts  and  the  oculo-motor  nuclei,  and 
that  the  integrity  of  the  connections  is  a  necessary  condition  of  reflex 
irido-motor  and  general  oculo-motor  reaction."  Like  other  physiolo- 
gists, he  finds  that  "lesions  of  the  corpora  quadrigemina  in  various 
animals  give  rise  to  marked  disturbances  of  equilibrium  and  irregu- 
larity of  movement,"  and  he  states  that  "  entire  removal  of  the  optic 
lobes  renders  station  and  locomotion  impossible."  Further,  he  found 
that  electrical  irritation  of  the  corpora  quadrigemina  is  followed  by 
well-marked  and  definite  phenomena,  and  that  irritation  of  the  nates, 
or  anterior  pair  of  tubercles,  produces  different  results  from  irritation  of 
the  testes.  These  phenomena  were  as  follows : — "  On  irritation,"  he  says, 
"  of  the  nates,  or  anterior  tubercles,  in  monkeys,  I  have  observed  the 
following  results  : — Irritation  of  the  one  side  causes  the  opposite  pupil 
to  become  widely  dilated,  followed  almost  immediately,  or  accompanied 
by,  dilatation  of  the  pupil  on  the  same  side.  The  eyes  are  widely 
opened  and  the  eyebrows  elevated ;  the  eyeballs  are  directed  upwards 
and  to  the  opposite  side ;  the  head  is  moved  in  the  same  direction 
as  the  eyes ;  the  ears  are  strongly  retracted.  If  the  irritation  is  kept 
up,  the  tail  is  elevated,  the  legs  extended,  the  arms  approximated  to 
tlie  sides,  drawn  back  and  flexed  at  the  elbows,  the  jaws  clenched,  and 
the  angles  of  the  mouth  retracted,  until  a  general  opisthotonus  ensues. 
The  motor  effects  are  first  shown  on  the  opposite  side  of  tlie  body,  but 
ultimately  both  sides  become  affected  by  the  unilateral  irritation. 

Irritation  of  the  testes,  or  posterior  tubercles,  causes  the  same  dila- 
tation of  the  pupils  and  general  motor  s}Tnptoms,  but  with  these,  and 
as  the  first  effect,  the  utterance  of  a  short  bark  or  cry  on  the  slightest 


TUMOURS  OF  THE  QUADRIGEMINA.  177 

contact  of  the  electrodes,  and  every  variety  of  vocalisation  when  the 
stimulation  is  continued." 

"  The  phenomena,"  he  states,  "  which  result  from  irritation, 
mechanical,  chemical,  or  electrical,  of  the  lamello3  of  the  corpora  quad- 
rigemina  or  optic  lobes,  appear  to  be  mainly,  if  not  exclusively,  of  a 
reflex  character,  and  are  such  as  may  result  from  irritation  of  sensory 
centres  or  tracts.  If  we  assume  that  in  the  corpora  quadrigemina 
sensory  impressions,  retinal  and  others,  are  co-ordinated  with  adaptive 
motor  reactions,  such  as  are  involved  in  equilibriation  and  locomotion, 
we  should  scarcely  expect  to  excite  these  otherwise  than  in  a  tumul- 
tuous and  ungraduated  manner  by  irritation  applied  to  the  centres 
themselves.  ...  So  also  the  dilatation  of  the  pupils,  which  is  so 
readily  induced  by  irritation  of  the  corpora  quadrigemina,  may  be 
regarded  as  a  sign  of  irritation  of  sensory  structures.  .  .  .  No  direct 
relation  has  been  satisfactorily  established  between  irritation  of  the 
nates  and  the  constringent  action  of  the  irido-motor  nucleus  of  the 
third  nerve.  This  is  a  fact  which  favours  the  views  of  those  who 
hold  that  the  corpora  quadrigemina  as  such  are  not  the  medium  of  the 
irido-constrictive  reaction  induced  by  stimulation  of  the  retina." 

"  The  phenomena,"  he  states,  "  occurring  on  irritation  of  the  nates 
and  testes  respectively  appear  to  me  to  be  the  result  of  irritation  of 
these  ganglia  as  such,  and  not  of  the  subjacent  tracts,  and  to  depend 
upon  the  structural  differences  between  the  anterior  and  posterior  pair 
of  tubercles." 

He  sums  up  his  opinion  as  follows  : — "  From  the  phenomena  occa- 
sioned by  electrical  or  other  forms  of  irritation  of  the  corpora  quadri- 
gemina or  optic  lobes,  it  would  appear,  therefore,  that  nothing  is  indicated 
with  any  degree  of  certainty  further  than  the  existence  of  retinal  and 
other  sensory  tracts  or  centres,  through  stimulation  of  which  general 
motor  reactions  are  capable  of  being  induced.  In  so  far,  however,  they 
support  the  hypothesis,  founded  on  the  effects  of  destructive  lesions, 
that  these  ganglia  form  an  essential  portion  of  the  mechanism  of  the 
co-ordination  of  retinal  and  general  sensory  impressions  with  the  mes- 
encephalic motor  apparatus  concerned  in  the  complex  responsive  ad- 
justments of  equilibriation  and  the  other  adaptive  reactions  of  which 
animals  are  capable  after  removal  of  the  higher  encephalic  centres."  ^ 

*  The  Functions  of  the  Brain,  Second  Edition,  Chapter  V. 
M 


178 


LOCAL  DIAGNOSLS. 


When  the  adjacent  motor  or  sensory  tracts  are  involved,  there  may 
of  course  be  paralysis  and  antesthesia  of  the  face  and  limbs  on  the 
side  opposite  to  that  of  the  motor  or  sensory  tract  which  is  implicated, 
or  hemianopsia  from  involvement  of  the  optic  tract.  Tumours  in 
the  region  of  the  corpora  quadrigemina  may  also  cause  dropsy  of 
the  ventricles,  and  the  general  (cerebral)  symptoms  which  result 
therefrom. 

Whether  lesions  (tumours)  of  the  corpora  quadrigemina  produce 


Fig.  58. — Photograph  of  Annie  B. — Case  of  ophthalmoplegia  externa 
acuta,  showing  the  facial  appearance  at  the  height  of  the  lesion. 

The  divergence  of  the  eyeballs,  the  ptosis,  the  compensatory  contraction 
of  the  occipitc-frontales  muscles,  and  the  markedly  stupid  apathetic  expres- 
sion of  countenance,  are  admirably  shovvii. 

any  alterations  of  vision,  except  dimness  or  loss  of  vision,  the  result 
of  double  optic  neuritis  or  post-neurotic  atrophy  (which  may,  as  we 
have  seen,  be  due  to  a  tumour  in  any  part  of  the  intracranial  cavity), 
or  hemianopsia  from  pressure  on  the  optic  tract,  seems  doubtful. 

Some    observers    think   that   the   muscular  inco-ordination   and 
muscular  spasms,  w^liich  seem  to  result  from  lesions  of  the  corpora 


TUMOURS  OF  THE  PONS  VAROLII. 


179 


quadrigemina,  are  due  to  destruction  or  irritation  of  the  subjacent 
tracts  in  the  pons  Varolii,  more  especially  the  superior  cerebellar 
peduncles  and  tegmental  tracts,  rather  than  to  the  lesion  of  the 
corpora  quadrigemina  themselves.  Ferrier,  while  admitting  that  it 
is  impossible  to  separate  the  lamellae  of  the  corpora  quadrigemina 
from  the  tegmental  tracts  with  which  they  are  in  relation,  states  "that 
it  is  probable  that  lesions  involving  the  subjacent  tracts  cause  more 
marked  and  enduring  disturbances  of  equilibrium ;  but  that  lesions 


■»^»M^w«!aiiiwyj^^^>^g>«a^ 


Fig.  59. — Photograph  of  Annie  B. — Case  of  ophthahnoplegia  externa 
acuta,  showing  the  appearance  on  recovery. 

This  photograph  was  taken  six  months  after  that  represented  in  Fig. 
58.  The  expression  is  now  bright  and  intelligent,  and  all  paralytic  symp- 
toms have  diappeared. 

not  directly  involving  these  tracts  are  sufficient  to  induce  marked 
disorders  of  equilibrium  is,  I  consider,  amply  demonstrated  by  the 
actual  facts  of  experiment."  ^ 

In  a  case  which  I  have  recorded  with  Mr.  Berry,  and  in  which 
the  symptoms  were,  I  think,  probably  due  to  a  scrofulous  lesion  at 

^  The  Functions  of  the  Brain,  Second  Edition,  p.  163. 


i8o 


LOCAL  DLAGNOSIS. 


the  top  of  the  pons  (involving  the  nuclei  of  origin  of  the  third  nerve, 
and  possibly  also  the  corpora  quadrigemina),  ophthalmoplegia  externa 
acuta  was  typically  developed  (see  Figs.  58  and  59) ;  there  was 
marked  general  stupor  (perhaps  due  to  ventricular  dropsy) ;  and 
screaming  fits,  in  which  the  jaws  and  hands  were  clenched,  which 
were  possibly  similar  to  the  screaming  fits  which  Ferrier  states  are 
characteristic  of  electrical  irritation  of  the  testes  of  the  corpora 
quadrigemina  in  the  lower  animals. 

It  is  possible,  but  extremely  unlikely,  that  a  tumour  at  the  top  of 
the  pons  Varolii  might  involve  individual  parts  of  the  third  nerve 


C.ct^ll. 


CcTK  'A 


H.uO 

-Rec£.tnt 

Fig.  60. — Sagittal  section  [of  the  skull  and  encephalon  of  the  dog 
(Hensen  and  Volckers). 

C.  call.,  corpus  callosum  ;  CW.  moll.,  commissure  mollis  ;  Ace,  centre 
of  accommodation;  Ir.,  centre  for  the  sphincter  iridis  ;  Rect.  int.,  centre 
for  the  rectus  internus  ;  R.  u.  0.,  centre  for  the  rest  of  the  ocular  muscles. 

nucleus,  and  so  produce  paralysis  of  accommodation  only,  abolition  of 
the  pupil  reflex  to  light  only,  or  paralysis  of  some  of  the  individual 
muscles  supplied  by  the  third  nerve. 

The  arrangement  of  the  different  component  parts  of  the  great 
nucleus  of  the  third  nerve  at  the  top  of  the  pons  Varolii  is  extremely 
complicated  and  interesting.  Thus  Hensen  and  Volckers  "have 
shown  that  the  nuclei  of  origin  of  the  third  nerve  contain  separate 
centres  for  the  individual  oculo-motor  actions.  After  removal  of  the 
cerebral  hemispheres   in  dogs,  they  found^  that  the  application   of 


TUMOURS  OF  THE  PONS  VAROLII. 


i8r 


electrical  stimulation  to  the  floor  of  the  aqueduct  of  Sylvius  and 
posterior  part  of  the  third  ventricle  gave  rise  to  different  ocular 
movements,  according  to  the  position  of  the  electrodes. 

"  Most  anteriorly,  in  the  wall  of  the  third  ventricle,  is  the  centre 
for  accommodation  (Fig.  60,  -4cc.)  acting  on  the  tensor  of  the  choroid 
through  the  anterior  root  fibres  of  the  third  nerve.  Behind  this  is 
the  centre  for  the  constrictor  fibres  of  the  iris  (Fig.  60,  J?-.). 

"  Next,  at  the  point  of  junction  of  the  third  ventricle  with  the 
aqueduct  of  Sylvius  is  the  centre  for  the  rectus  internus  (Fig.  60, 


Fig.  61. — Longitudinal  ventrical  section  through  the  human  brain, 
showing  (diagrammatically)  the  position  of  the  nerve  nuclei  of  the  ocular 
muscles. 

A,  testes,  and  B,  nates  of  corpora  quadrigemina  ;  C,  cerebellum  ;  D, 
pineal  gland  ;  E,  soft  commissure  in  the  middle  of  the  third  ventricle, 
which,  with  the  aqueduct  of  Sylvius  and  fourth  ventricle,  are  represented  in 
black  ;  F,  the  protuberance  of  the  pons  ;  G,  medulla  oblongata  ;  1  to  6, 
different  parts  of  the  third  nerve  nucleus,  viz. — 1,  centre  for  accommoda- 
tion ;  2,  centre  for  sphincter  of  the  pupil  ;  3,  centre  for  internal  rectus  ;  4, 
centre  for  the  rectus  superior  ;  5,  centre  for  the  levator  palpebraj  superioris  ; 
6,  centre  for  the  rectus  superior  ;  7,  centre  of  the  fourth  nerve  (trochlearis)  for 
the  superior  obhque  ;  8,  centre  of  the  sixth  nerve  for  the  external  rectus. 

Med.  int.),  and  further  in  order  backwards,  centres  for  the  rectus 
superior,  levator  palpebrse  superioris,  rectus  inferior,  and  lastly,  that 
of  the  trochlearis  or  obliquus  superior,  the  centre  of  which  lies  below 
the  testes  and  somewhat  laterally  (Fig.  60,  B.  u.  0.)."  ^ 

^  Quoted  from   Ferrier'a   Functions   of  the   Brain,    Sacond  Edition,    p.   152.      The 
original  paper  will  be  found  in  the  Archiv  f.  Ophthcdmologie,  Bd.  xxiv.,  1878. 


i82  LOCAL  DLAGNOSLS. 

In  Fig.  61  a  longitudinal  vertical  section  of  the  human  brain 
is  represented,  the  nerve  nuclei  being  (diagrammatically)  placed  in 
the  same  position  from  before  backwards  as  Hensen  and  Volckers 
have  shown  to  be  tlie  case  in  the  dog. 

Kahler  and  Pick  come  to  a  slightly  different  conclusion  as  to  the 
relative  positions  of  the  different  nuclei.  Whilst  admitting  (what 
indeed  there  is  now  abundant  clinical  experience  to  lead  one  to 
look  upon  as  an  established  fact)  that  the  centres  for  the  nerve 
supply  to  the  sphincter  pupillte  and  ciliary  muscle  lie  detached  from 
those  for  the  fibres  passing  to  the  external  muscles,  also  supplied  by 
the  third  nerve,  they  were  led  from  the  post-mortem  examination  in 
two  cases  of  incomplete  nuclear  paralysis  of  the  third  nerve  (in  one 
of  whicli  the  elevators  of  the  eye  and  lid  were  alone  affected,  and  in 
the  other,  mainly  the  internal  rectus),  to  locate  the  nuclei  of  the 
nerves  to  the  elevator  muscles  in  a  line  lying  to  the  outer  side  of 
those  destined  for  the  supply  of  the  internus  and  inferior  rectus. 
This  would  bring  the  nuclei  of  such  fibres  as  are  physiologically 
associated  into  immediate  proximity  to  each  other — an  arrangement 
which  would  seem  more  probable  even  a  -priori  than  that  given  in 
Hensen  and  Volckers'  scheme. 


Tumours  of  the  2nneal  gland  are  probably  more  common  than 
tumours  of  the  corpora  quadrigemina.  The  localising  symptoms 
which  they  produce  are  very  similar  to  those  Avhich  result  from 
lesions  of  the  corpora  quadrigemina,  and  are  in  fact  due  to  involve- 
ment of  these  structures  and  of  the  adjacent  parts  (crus  cerebri,  pons 
Varolii,  &c.),  and  to  dropsy  of  the  ventricles. 

Tumours  m  the  lateral  half  of  the  pons,  below  its  upper  third  (i.e., 
below  the  point  at  which  the  fibres  of  the  facial  muscles  leave  the 
main  pyramidal  tract  to  decussate  in  their  passage  to  their  nerve 
nucleus  on  the  opposite  side),  may  cause  those  forms  of  "  alternate  " 
hemiplegia  in  which  («)  the  arm  and  leg  are  paralysed  on  the  opposite, 
and  the  muscles  supplied  by  the  facial  nerve  on  the  same  side  as  the 
lesion  (see  Fig.  57,  page  175) ;  or  (6)  the  arm  and  leg  on  the  opposite 
and  the  face  on  both  sides  (see  Fig.  62) ;  or  (c)  the  arm  and  leg  on 


TUMOURS  OF  THE  PONS  VAROLII. 


183 


the  opposite  side  aud  the  muscles  supplied  by  the  sixth  or  motor 
portions  of  the  fifth  nerve  on  the  same  side.* 

Alternate  hemi-ansesthesia,  anaesthesia  of  the  arm  and  leg  on  the 
opposite,  and  of  the  head  and  face,  i.e.,  the  parts  supplied  by  the 
fifth  nerve  on  the  same  side ;  or  anaesthesia  of  the  arm  and  leg  on  the 
opposite,  and  of  the  head  and  face  on  both  sides,  may  also  be  pro- 
duced in  the  same  manner. 


/ 


Til 


-f'm 


Fig.  62. — Diagram  showing  a  lesion  in  the  right  half  of  the  pons 
Varohi,  causing  paralysis  of  both  sides  of  the  face,  and  of  the  arm  and  leg 
on  the  opposite  left  side. 

The  letters  F,A,L  point  to  the  motor  tracts  for  the  left  side  of  the  face, 
arm,  and  leg,  as  they  enter  the  right  side  of  the  pons  Varohi  (P)  in  their 
passage  from  the  right  hemisphere  of  the  brain.  (Compare  with  Eig.  14, 
page  69.) 

A  lesion  in  the  position  of  8  (middle  of  the  right  side  of  the  pons)  may 
cause  paralysis  of  the  opposite  arm  and  leg,  and  of  both  sides  of  the  face 
(/m  and/'wi),  by  intercepting  the  motor  fibres  proceeding  to  the  left  side 
of  the  face  {fin),  before  they  have  decussated,  and  those  passing  to  the 
right  side  of  the  face  ( /  m)  after  they  have  decussated. 

Should  the  root  fibres  or  trunk  of  the  fifth  nerve  be  irritated 
rather  than  destroyed,  neuralgic  pains  more  or  less  violent  in  degree 
would  be  observed  in  the  area  of  distribution  of  the  affected  nerve. 

The  sensory  impairment,  which  results  from  lesions  in  the  pons 
Varolii,  is  seldom  so  well  marked  or  so  definite  in  its  distribution  as 
the  motor  paralysis.  An  exception  to  this  statement,  however,  occurs 
in  those  cases  in  which  the  tumour  involves  the  sensory  portion  of 
the  crusta,  or  the  root  fibres  or  trunk  of  the  fifth  nerve. 

^   The  Functions  of  the  Brain,  Second  Edition,  p.  163. 


1 84 


LOCAL  DLAGNOSLS. 


Combinations  of  alternate  hemiplegia  and  alternate  hemi-anses- 
thesia,  or  of  the  different  forms  of  alternate  hemiplegia,  may  of 
course  occur. 

When  the  lesion  (tumour)  is  so  situated  as  to  involve  both  sides 
of  the  pons  and  both  pyramidal  tracts,  all  four  limbs  may  be  para- 
lysed ;  in  such  cases  the  loss  of  motor  power  is  seldom  complete  or 
equally  great  on  both  sides  of  the  body. 

In  rare  cases,  paralysis  of  one  limb  (monoplegia)  is  due  to  a  lesion 


Fig.  63. — Transverse  vertical  section  through  the  brain  at  the  level  of 
the  greatest  convexity  of  the  pons  Varolii,  in  a  case  of  melanotic  sarcoma, 
showing  the  position  of  melanotic  nodules  {Q,R  8)\a.  the  brain,  and  a  large 
nodule  {T)  in  the  pons,  involving  the  right  pyramidal  tract.  (Reduced 
from  a  photograph. ) 

(tumour)  in  the  pons ;  in  one  case  of  the  kind,  described  by  Dr.  Allan 
Jamieson  and  myself  in  the  Ediiibiirgh  Medical  Journal  for  July 
1887,  page  40,  and  represented  in  Fig.  63,  the  paralysis  became  more 
extensive  as  the  case  progressed,  and  ultimately  involved  the  face, 
arm,  and  leg,  on  the  opposite  side  of  the  body. 

A  tumour  in  this  situation  may  also  involve  the  nerve  nuclei  or 
root  fibres  of  nerves  originating  in  the  pons  on  one  or  both  sides  (see 
Mg.  64).  A  tumour  originating  in  the  neighbourhood  of  the  middle 
line  (median  raphe)  may  involve  the  nerve  nuclei  of  both  sixth  nerves 
and  cause  double  internal  strabismus.  In  cases  of  this  description, 
the  external  rectus  muscle  on  one  side  is  usually  paralysed  before,  or 
in  a  greater  degree  than,  that  on  the  other. 

In  some  cases  of  tumour  of  the  pons  Varolii,  vomiting  is  mark  ed. 
In  others,  dementia  and  stupor  are  great,  probably  as  the  result  of 


TUMOURS  OF  THE  PONS  VAROLII. 


185 


copious  ventricular  dropsy,  which  is  common  in  large  tumours  of  the 
pons,  and  indeed  in  all  large  subtentorial  new  growths. 

Deafness  is  not  common,  but  it  has  been  occasionally  observed ; 
it  seems  to  be  due  either  to  direct  pressure  upon  the  auditory  nerve, 
or,  according  to  Eoss,  to  the  tumour  being  situated  so  as  to  involve 
the  middle  peduncle  of  the  cerebellum.  Eoss  states  that  he  has  seen 
"  two  cases  "  in  which  the  tumour  had  extended  from  the  middle 


Fig.  64. — Camera  lucida  drawing  of  a  transverse  section  through  the 
pons  Varolii,  showing  a  small  tubercular  tumour  in  the  upper  surface  of  the 
left  half.  (Very  slightly  magnified  —  Hartnack,  oc.  2,  obj.  1,  and  drawing 
reduced  from  8^  to  2f  inches. ) 

The  section  was  stained  with  picro-carmine  and  mounted  in  Tarrant's 
solution. 

The  letter  A  points  to  the  fibres  of  the  sixth  nerve  on  the  right  side  ; 
they  are  not  implicated.  The  letter  B  points  to  the  tumour,  which  has 
destroyed  the  fibres  of  the  sixth  nerve  on  the  left  side.  In  the  centre  of  the 
tumour  there  are  several  caseous  masses.  The  letters  0  C  point  to  the 
pyramidal  tracts. 

peduncle  of  the  cerebellum  to  the  pons,  and  in  which  unilateral  deaf- 
ness was  an  early  and  marked  symptom.^ 

Disorders  of  equilibriation,  or  a  tendency  to  fall  to  one  side,  &c., 
are  present  in  some  cases  of  tumour  of  the  pons  Varolii,  and,  in 
many  cases  appear  to  depend  upon  involvement  of  the  middle 
peduncle  of  the  cerebellum. 

Conjugate  deviation  of  the  head  and  eyes  may  be  due  to  a  lesion 

^   The  Diseases  of  the  Nervous  System,  vol.  ii. ,  p.  591. 


1 86  LOCAL  D  LAG  NO  SIS. 

in  the  pons  Varolii.  It  is,  however,  much  more  hkely  to  be  asso- 
ciated with  acute  lesions,  such  as  hsemorrhagic  extravasations,  than 
with  tumours. 

The  conjugate  deviation  of  the  head  and  eyes,  which  is  due  to  a 
lesion  of  the  pons  Varolii,  differs,  as  regards  its  direction,  from  the 
conjugate  deviation  of  the  head  and  eyes  due  to  a  lesion  of  the  hemi- 
spheres. In  lesions  of  one  lateral  half  of  the  pons,  the  head  and  eyes 
are  turned  away  from  the  side  of  the  lesion  {i.e.,  towards  the  paralysed 
limbs)  when  the  deviation  is  paralytic,  and  toiuards  the  lesion  {i.e., 
towards  the  side  which  is  not  convulsed — in  other  words,  from  the 
limbs  which  are  convulsed)  when  the  deviation  is  spasmodic. 

In  those  cases,  on  the  other  hand,  in  which  the  lesion  is  situated 
in  the  cerebral  hemisphere,  the  deviation  is  toioarcls  the  lesion  {i.e., 
towards  the  sound  side,  or  away  from  the  paralysed  limbs)  when  it  is 
paralytic,  and  away  from  the  lesion  {i.e.,  towards  the  limbs  which  are 
convulsed)  when  the  deviation  is  due  to  spasm. 

Difficulty  in  swallowing,  paralysis  of  the  tongue,  paralytic  diffi- 
culties of  speech,  vaso-motor  disturbances,  polyuria,  glycosuria,  and 
disturbances  in  the  action  of  the  heart  or  respiration,  may  also  be 
caused  by  tumours  in  the  pons  Varolii.  These  are  for  the  most  part 
late  phenomena,  and  are  especially  apt  to  occur  when  the  medulla 
oblongata  is  pressed  upon  or  otherwise  involved  by  the  lesion. 

In  some  cases  of  tumour  of  the  pons,  sudden  death  occurs, 
apparently  in  consequence  of  paralysis  of  the  respiratory  or  cardiac 
centres. 

TUMOUES  OF  THE  MeDULLA  ObLOJ^GATA. 

Tumours  originating  within  the  medulla  oblongata  are  rare ; 
they  are  usually  of  small  size,  and  are  generally  situated  in 
the  neiglibourhood  of  the  fourth  ventricle.  Headache  is  usually  pre- 
sent ;  but,  in  the  earlier  stages,  may  be  absent  or  slight.  Double 
optic  neuritis  is  perhaps  more  frequently  absent  than  in  tumours  in 
other  parts  of  the  cranial  cavity,  possibly  because  of  the  small  size  of 
the  tumour  and  the  absence  of  any  great  increase  of  the  intracranial 
pressure ;  but  this  point  (the  frequency  of  optic  neuritis  in  the  case 
of  tumours  of  the  medulla)  requires  further  investigation.  Vomiting 
is  generally  very  prominent  and  urgent ;  hiccough  is  common. 


TUMOURS  OF  THE  MEDULLA  OBLONGATA.         187 

In  addition  to  hiccough  and  urgent  vomiting,  other  localising 
symptoms,  due  to  involvement  of  the  eighth,  ninth,  tenth,  eleventh, 
or  twelfth  nerves,  or  to  the  encroachment  of  the  new  growth  upon  the 
pons  Varolii  or  cerebellum,  together  with  paralysis  of  the  limbs  from 
pressure  on,  or  involvement  of,  the  pyramidal  tracts  in  the  medulla 
itself,  may  be  present. 

Bulbar  symptoms — difficulty  in  articulation  from  paralysis  of  the 
lips,  tongue,  palate,  or  larynx — are  specially  characteristic  and  im- 
portant. In  some  cases,  there  is  glycosuria,  polyuria,  or  albuminuria. 
The  pulse  frequency  may  be  unduly  slow.  Cheyne- Stokes  respiration 
is  often  present  towards  the  termination  of  the  case.  Sudden  death 
may  occur  from  failure  of  the  respiration,  or  perhaps  from  paralysis 
of  the  heart. 

Paralysis  of  the  limbs,  which  may  be  absent  when  the  tumour  is 
situated  in  the  neighbourhood  of  the  fourth  ventricle,  is  usually  pre- 
sent in  a  greater  or  less  degree,  when  the  tumour  involves  the  anterior 
surface  of  the  medulla,  or  presses  upon  the  pyramids  from  without. 
Tumours  which  press  upon  the  medulla  from  without  are,  as  has  been 
already  pointed  out,  more  apt  to  produce  alternate  hemiplegia,  with 
paralysis  of  the  tongue  on  the  same  side,  than  those  new  growths 
which  are  situated  within  the  medulla  itself. 

Sensory  disturbances  (angesthesia)  are  seldom  prominent.  Un- 
steadiness of  gait,  resembling,  it  is  said,  that  due  to  cerebellar  disease, 
has  been  met  with  in  some  cases,  more  especially  when  the  tumour  is 
situated  in  the  neighbourhood  of  the  fourth  ventricle. 

TUMOUKS   OF   THE   CEREBELLUM. 

The  cerebellum  is  a  frequent  seat  of  new  growths,  especially  of 
scrofulous  tumours.  The  symptoms,  which  are  in  many  cases  striking 
and  characteristic,  may  be  due  partly  to  derangement  of  the  function 
of  the  cerebellum  itself,  partly  to  pressure  upon  the  pons  Varolii  and 
medulla  oblongata,  and  partly  to  the  increased  intracranial  pressure 
(and  perhaps  diffuse  irritative  changes  throughout  the  brain)  which 
results  from  extensive  ventricular  dropsy. 

The  headache  in  cases  of  cerebellar  tumour  may  be  very  severe, 
and  is  often  referred  to  the  back  of  the  head,  but  is  not  infrequently 


i88 


LOCAL  DLAGNOSLS. 


frontal.  In  a  small  proportion  of  cases  there  is  also  tenderness  on 
percussing  the  skull  in  the  occipital  region.  Vomiting  is  very  gene- 
rally present.  When  very  severe,  it  is  probably,  in  some  cases  at  all 
events,  the  result  of  irritation  of  the  pons  Varolii  or  medulla  oblongata. 
Ferrier  states  that  he  never  observed  vomiting  as  a  result  of  electrical 
stimulation  of  the  cerebellum  in  the  lower  animals.  DouUe  optic 
neuritis  is  usually  well  marked,  and  is  in  many  cases  intense,  associ- 
ated with  loss  of  vision,  and  followed  by  optic  atrophy.  General 
mental  imiKiirment  (stupor,  &c.)  may  be  considerable,  more  especially 
in  those  cases  in  which  the  ventricular  dropsy  is  great.  General  con- 
vulsions occasionally  occur.  In  the  case  which  is  represented  in  Tigs. 
65  and  66  the  patient  died  in,  what  was  said  to  be,  an  epileptic  fit. 

In  some  cases  (more  especially 
in  those  in  which  the  tumour  is 
of  small  size,  of  slow  growth,  and 
situated  in  the  lateral  lobe  of  the 
cerebellum)  there  are  no  special 
symptoms  indicative  of  the  seat 
of  the  lesion.  An  unsteady,  ir- 
regular, reeling  gait,  very  like  that 
due  to  alcoholic  intoxication,  is 
the  most  common  and  important 
localising  symptom.  The  exact 
cause  of  the  unsteadiness  is  a 
matter  of  debate.  With  Hugh- 
lings  Jackson,  I  have  been  in  the 
habit  of  regarding  it  as  in  some 

Fig.  65.— Portions  of  the  temporal  and  caSCS    paralytic,  and  duC  to  weak- 
occipital  bones,  sho\ving  a  round  tumour  (^4)  _ 

about  the  size  of  a  greengage  plum,  springing  nCSS   m   the   mUSClCS  01  the  back; 

from  the  dura.     The  tumour  was  situated  .        ,,  ,     •  j*      i.*        •      j.i 

immediately  below  the  tentorium,  and  had  ^  Others  tO  mCO-OrdmatlOn  Ul  the 

caused  a  deep  indentation  in  the  left  lobe  of  g^^^-^g  p^^,|.g  (niUSclcS  of  the  trunk), 
the  cerebellum. 

Ferrier  tliiuks  that  it  is  not  due 
to  paralysis,  but  to  an  inability  to  co-ordinate  the  muscular  adjust- 
ments required  to  maintain  equilibrium  or  balance ;  that  it  is  in  fact 
a  form,  but  a  peculiar  form,  of  ataxia  (cerebellar  ataxia). 

Cerebellar  ataxia  differs  in  certain  important  particulars  from  the 
ataxia  due  to  tabes  dorsalis.     When  the  patient  stands  with  the  legs 


TUMOURS  OF  THE  CEREBELLUM. 


189 


wide  apart,  the  startings  of  the  tendons,  which  are  often  present  in 
locomotor  ataxia,  are  not  observed.  The  unsteadiness,  too,  is  not 
markedly  aggravated  by  closure  of  the  eyes,  and  there  are  no  disturb- 
ances of  tactile  sensibility,  nor  of  the  muscular  sense.  The  irregular 
jerky  movements  of  the  legs  which  characterise  the  gait  of  locomotor 
ataxia  are  not  present.  Abolition  of  the  knee  jerk  is  in  favour  of  loco- 
motor ataxia  ;  but  it  is  not  a  certain  guide  to  diagnosis,  for  it  may 
also  be  lost  in  cerebellar  disease. 

In  those  cases  of  cerebellar  disease  in  which  the  patient  is  blind 
from  optic  neuritis,  or  post-neurotic  atrophy,  the  gait  may  of  course 


EiG.  66. — Cerebellum  showing  a  deep  indentation  in  its  left  lobe  produced 
by  the  tumour  shown  in  Figure  65,  The  cerebellar  tissue  was  simply 
atrophied  ;  there  were  no  signs  of  inflammation  or  softening  in  the  neigh- 
bourhood of  the  lesion. 

The  case  is  recorded  in  the  Edinhuryh  Medical  Journal  for  June  1879, 
page  1072. 

be  uncertain  (like  that  of  a  man  whose  eyes  are  bandaged)  indepen- 
dently of  any  true  ataxia. 

The  unsteady,  reeling  gait  is  not  present  in  all  cases  of  tumour  of 
the  cerebellum.  Small  lesions,  and  even  large  lesions  of  slow  growth, 
which  produce  destruction  rather  than  irritation  of  the  cerebellar 
tissue,  may  be  compensated  by  voluntary  efforts,  i.e.,  by  the  action  of 
the  higher  (cerebral)  centres.  In  such  cases  the  unsteadiness  of  gait 
and  difficulty  in  maintaining  the  equilibrium  may  be  slight,  or 
difficult  to  detect ;  but  when  the  whole  cerebellum  has  been  involved 


I90  LOCAL  DLAGNOSLS. 

by  disease,  or  has  been  found  greatly  or  completely  atrophied,  careful 
observation  has,  says  Terrier,  "  never  failed  to  discover  a  greater  or  less 
degree  of  awkwardness  of  movement  and  instability  of  equilibrium."  ^ 

The  reeling  gait  seems  to  be  most  marked,  and,  according  to  some 
observers,  only  present,  when  the  middle  lobe  is  invaded,  I  have  met 
with  the  most  characteristic  reeling  gait  in  cases  in  which  the  tumour 
involved  one  lateral  lobe  or  the  middle  peduncle,  and  in  which  the 
middle  lobe  was  not  directly  involved,  though  it  may  have  been 
pressed  upon. 

The  disorder  of  equilibrium  is  greatest  in  those  cases  in  which 
the  lesion  is  unsymmetrical  and  unilateral ;  and  it  is  probable  that  in 
man,  as  in  the  lower  animals,  the  equilibrium  is  deranged  in  different 
ways  in  different  cases,  the  exact  character  of  the  disorder  depending 
upon  (1)  the  exact  part  of  the  cerebellum  which  is  involved,  and  (2) 
the  manner  in  which  it  is  affected,  i.e.,  whether  irritated  or  destroyed. 

The  unsteadiness  of  gait  is  in  some  cases  associated  with,  but  is 
not  the  result  of  vertigo ;  for  cerebellar  ataxia  may  be  present  without 
any  giddiness  whatever.  Marked  vertigo  is  nevertheless  suggestive 
of  a  cerebellar  lesion.  It  is  also  probable  that  the  character  of  the 
vertigo  (the  direction  in  which  the  patient  thinks  objects  are  moving 
past  him,  or  the  direction  in  which  he  feels  as  if  he  himself  were 
being  moved  or  whirled)  varies  with  the  exact  part  of  the  cerebellum 
which  happens  to  be  affected.  It  would  appear  that  in  different 
parts  of  the  cerebellum  there  are  separated  and  distinct  centres,  to 
which  the  nerves  from  the  different  semicircular  canals  of  the  internal 
ear  and  other  peripheral  end-organs  concerned  in  the  maintenance  of 
balance  proceed,  and  from  which  the  necessary  motor  adjustments  are 
distributed.  Ferrier  states  that  "  the  cerebellum  would  therefore  seem 
to  be  a  complex  arrangement  of  individually  differentiated  centres, 
which  in  associated  action  regulate  the  various  muscular  adjustments 
necessary  to  maintain  equilibrium  and  steadiness  of  the  body,  each 
tending  to  the  displacement  of  the  equilibrium  round  a  horizontal, 
vertical,  or  intermediate  axis  acting  as  a  stimulus  to  the  special 
centre  which  calls  into  play  the  antagonistic  or  compensatory 
action.  We  should  therefore  expect  to  find  that  a  lesion  which 
annihilates  the  functional  activity  of  any  of  the  individual  cerebellar 

^  Thi  Functions  of  the  Brain,  Second  Edition,  p.  180. 


TUMOURS  OF  THE  CEREBELLUM.  191 

centres  should  manifest  itself  in  a  tendency  to  the  overthrow  of 
the  balance  in  the  direction  naturally  opposed  by  this  centre.  This 
also  is  in  accordance  with  the  facts  of  experiment."  And  again — 
"  Assuming,"  he  says,  "  the  seat  of  irritation  to  be  correctly  indicated 
by  Crum  Brown,  we  should  regard  the  superior  vertical  canal  as  the 
afferent  of  the  posterior  cerebellar  centres,  the  posterior  vertical 
canal  as  the  afferent  of  the  anterior  cerebellar  centres,  and  the 
horizontal  canal  as  the  afferent  of  the  corresponding  lateral  centres."  ^ 

In  the  case  which  is  represented  in  Fig.  7,  page  33,  vertigo  was  a 
very  prominent  symptom,  and  the  patient  complained  that  when  the 
eyes  were  open,  the  ceihng  seemed  to  be  falling  down  on  the  top  of  her. 

Ferrier  has  shown  that  electrical  irritation  of  the  cerebellum  in 
the  monkey  and  other  animals  produces  a  series  of  movements  of  the 
eye,  head,  and  trunk,  and  that  the  exact  character  of  these  movements 
depends  upon  the  exact  part  of  the  cerebellum  to  which  the  irrita- 
tion is  applied.  According  to  him,  the  following  effects  are  produced 
by  destruction  and  irritation  of  different  parts  of  the  cerebellum  ;  and 
it  seems  probable,  from  what  we  know  of  cerebellar  disease  in  man, 
that,  in  some  cases  at  all  events,  somewhat  similar  phenomena  may  be 
noticed.     Nystagmus  is  not  uncommon  in  cases  of  cerebellar  tumour. 

Destruction  of  the  anterior  part  of  the  middle  lohe  produces  a  ten- 
dency to  fall  forwards,  while  irritation  of  the  same  part  excites  the 
muscular  combinations  which  would  counteract  this  tendency,  viz., 
backward  movement  of  the  head,  extension  of  the  trunk  and  limbs, 
together  with  upward  movement  of  the  eyes.  These  objective  phe- 
nomena are  probably  accompanied  by  the  subjective  sensation  of  being 
revolved  like  a  wheel  on  a  horizontal  axis  from  behind  forwards. 

Destruction  of  the  posterior  part  of  the  middle  lohe  produces  a 
tendency  to  fall  backwards,  while  irritation  of  the  same  part  calls 
into  play  the  muscular  adjustments  necessary  to  counteract  this 
tendency,  viz.,  forward  movements  of  the  head  and  downward  move- 
ment of  the  eyes.  These  objective  phenomena  are  probably  accom- 
panied with  the  subjective  sensation  of  being  rotated  hke  a  wheel  on 
a  horizontal  axis  from  before  backwards. 

Lesions  of  the  lateral  lohes  or  of  the  middle  pedtmcle  are,  when  com- 
plete, followed  by  rotatory  movements,  which  in  man  would  be  round 

^  The  Functions  of  the  Brain,  Second  Edition,  p.  199  et  seq. 


192  LOCAL  DLAGNOSLS. 

a  vertical  axis  towards  the  sound  side  {%.&.,  away  from  the  lesion). 
After  complete  destruction  of  the  lateral  lobe  or  left  middle  peduncle, 
the  patient  would  spin  round  and  round  from  right  to  left.  This 
rotation  M-ould  probably  be  accompanied  by  the  subjective  sensation 
of  vertigo,  and  of  objects  moving  before  the  eyes  from  right  to  left. 

Incomplete  lesions  of  the  lateral  lobe  or  of  the  middle  peduncle 
may,  instead  of  causing  a  movement  of  rotation,  cause  a  tendency  to 
fall  backwards  and  to  the  opposite  side. 

"  The  tendency,"  says  Ferrier,  "  in  simple  and  uncomplicated  irri- 
tation seems  to  be  overthrow  of  the  balance  towards  the  side  of 
irritation,  or  in  some  axis  inclining  in  this  direction.  .  .  .  But  the 
direction  in  which  the  balance  is  overthrown  is  not  always  towards 
the  side  of  irritation,  for  I  have  observed  it  in  several  patients  clearly 
towards  the  opposite  side.  This  is  probably  due  to  over-compensa- 
tion.- The  sense  of  falling  to  one  side  causes  active  volitional  effort 
on  the  part  of  the  individual,  so  that  he  falls  in  reality  towards  the 
opposite  side.  It  is  the  presence  of  the  hemispheres,  and  the  inter- 
vention of  conscious  and  volitional  efforts,  which  complicate  all  the 
properly  reflex  phenomena  of  cerebellar  adjustments.  Hence  it  is  that 
irritation  of  one  side  of  the  cerebellum  causes  the  feeling  of  rotation 
towards  or  loss  of  support  on  the  other  side,  because  as  the  action 
which  is  called  forth  is  in  reality  the  adjustment  to  counteract  such 
displacement,  the  two  become  indissolubly  associated  in  consciousness, 
and  the  one  effort  invariably  calls  up  the  other.  The  feeling  of  loss  of 
support  on  the  opposite  side  of  the  body  may  be  regarded  as  analogous 
to  the  apparent  vanishing  of  objects  in  the  same  direction."  ^ 

As  a  matter  of  fact,  a  tendency  to  fall  in  some  particular  direction 
is  frequently  observed  in  cases  of  cerebellar  disease  in  man.  Vertigo, 
too,  of  a  definite  kind  may  also  occur.  Eotatory  movements,  with 
movements  of  the  head  and  eyes,  such  as  result  from  stimulation  of 
different  parts  of  the  cerebellum  in  the  lower  animals,  are  much  more 
rare,  possibly  because  tumours  of  the  cerebellum  act  more  frequently 
as  "  destroying  "  than  as  "  discharging  "  lesions,  and  the  effects  of  slow 
destruction  are  compensated  by  voluntary  effort. 

Tumours  of  the  middle  lobe  of  the  cerebellum  are  said  to  be  at- 
tended, in  about  one-tliird  of  the  cases,  with  symptoms  of  sexual 

1    The  Functions  of  the  Brain,  Second  Edition,  p.  212. 


TUMOURS  OF  THE  CEREBELLUM.  193 

excitement — increased  sexual  desire,  and  in  males  frequent  erections 
with  or  without  emissions.  According  to  Bastian,  ^  this  genital  excite- 
ment is  perhaps  due,  not  so  much  to  disease  in  the  cerebellar  tissue,  as 
to  the  irritation  which  such  disease  may  set  up  in  the  posterior  aspect 
of  the  bulb — a  view  which  seems  supported  by  the  experimental 
observations  of  Ferrier,  who  never  observed  any  sign  of  excitement  of 
the  generative  organs  in  any  of  the  animals  experimented  on.^ 

In  addition  to  cerebellar  ataxia,  various  other  motor  derangements 
may  occur  in  cases  of  cerebellar  tumour.  Convulsive  movements  of 
a  tonic  kind,  which  may  affect  the  muscles  of  the  head  and  neck, 
trunk  and  limbs,  and  wliich  produce  in  some  cases  retractions  of  the 
head,  curving  of  the  spine,  and  an  appearance  closely  resembling  a 
tetanic  fit,  are  sometimes  observed  in  cerebellar  disease.  In  some 
cases  these  tonic  convulsive  movements  are  paroxysmal,  in  others  the 
affected  muscles  are  more  or  less  continuously  rigid,  the  head  being 
retracted,  or  the  trunk  and  limbs  rigidly  extended. 

The  exact  significance  of  these  tonic  spasms  and  contractions  is 
doubtful.  Some  authorities,  such  as  Huglilings  Jackson  and  Stephen 
Mackenzie,  think  that  they  are  due  to  irritation  and  discharge  of 
nerve  tissue  in  the  cerebellum  itself.  It  is  possible  that  in  some 
cases  (more  especially  where  the  convulsive  movements  resemble  the 
movements  which  result  from  electrical  irritation  of  the  cerebellum 
in  the  lower  animals)  this  is  so.  But  I  agree  with  those  who 
think  that  the  rigidity  and  tetanic-like  spasms  met  with  in  cerebellar 
disease  are  in  most  cases  due  to  the  cerebellar  lesion  pressing  upon, 
and  producing  irritation  and  discharge  of  grey  matter  in  the  pons 
Varolii  or  medulla  oblongata. 

Tremor,  associated  with  voluntary  movement,  closely  resembling 
the  tremor  of  cerebro-spinal  sclerosis,  is  sometimes  seen,  and  is  ap- 
parently caused  by  the  pressure  of  the  cerebellar  tumour  upon  the 
pons  Varolii  or  medulla  oblongata,  and  the  irregular  transmission  of 
motor  nerve  impulse,  through  the  fibres  of  the  pyramidal  tracts,  which 
results  therefrom. 

Paralysis  of  the  limbs  may  also  be  produced  in  the  same  manner. 
When  the  pyramidal  tract  on  one  side  is  pressed  upon,  the  arm  and 

1  Paralysis  :  Cerebral,  Bulbar,  and  Spinal,  p.  348. 
-   The  Functions  of  the  Brain,  Second  Edition,  p.  190. 
N 


194  LOCAL  DLAGNOSLS. 

leg  on  the  opposite  side  are  affected,  for  the  pressure  involves  the 
fibres  of  the  pyramidal  tract  above  its  decussation  in  the  medulla.  In 
this  respect  the  paralysis  which  results  from  the  pressure  of  a  cere- 
bellar tumour  upon  the  pons  Varolii  or  medulla  oblongata,  differs  from 
the  motor  impairment  associated  with  cerebellar  ataxia,  which  is 
found  on  the  same  side  as  the  cerebellar  lesion.  This  is  of  course 
due  to  the  fact  that  the  middle  peduncles  of  the  cerebellum,  which 
connect  the  lateral  lobe  of  the  cerebellum  with  the  pyramidal  tracts, 
decussate  in  the  pons.  The  riglit  lateral  lobe  of  the  cerebellum  is 
consequently  in  this  manner  brought  into  relationship  with  the 
left  pyramidal  tract,  as  it  lies  in  the  pons ;  in  other  words,  with  the 
pyramidal  tract  proceeding  to  the  right  (the  same  side)  of  the 
body. 

In  some  cases  of  cerebellar  tumour,  both  pyramidal  tracts  are 
pressed  upon,  and  the  resulting  paralysis  involves  both  sides  of  the 
body,  though  not  necessarily  in  the  same  degree. 

The  facial  muscles  are  rarely  paralysed  unless  the  tumour  presses 
directly  upon  the  trunk  of  the  facial  nerve. 

Deafness  may  be  produced  in  the  same  manner  (by  direct  pressure 
on  the  auditory  nerve),  but  does  not  seem  to  be  caused  by  lesions  of 
the  cerebellum  itself.  In  one  of  my  cases  of  cerebellar  tumour,  which 
has  been  previously  referred  to,  total  deafness  was  suddenly  produced, 
apparently  from  sudden  increase  of  the  intracranial  pressure. 

Dimness  of  vision  is  often  due  to  optic  neuritis  or  oj)tic  atrophy, 
but  is  not  directly  caused  by  the  cerebellar  lesion. 

Contraction  of  the  pupils  on  the  same  side,  and  twitching  of  the 
ears,  were  observed  by  Terrier  to  result  from  electrical  irritation  of 
the  cerebellum ;  but  whether  any  alterations  in  the  size  of  the  pupil 
result  from  cerebellar  tumours  in  man,  I  do  not  know. 

Enlargement  of  the  head  is  not  uncommon  in  young  subjects,  as 
the  result  of  copious  ventricular  dropsy,  and  when  it  occurs  is  of  some 
importance  as  a  locahsing  sign  of  tumours  of  the  middle  lobe,  with 
which  extensive  ventricular  dropsy  is  most  frequently  associated. 
The  enlargement  is  bilateral,  associated  with  opening  up  of  the 
sutures,  and  exactly  resembles  the  enlargement  of  ordinary  chronic 
hydrocephalus. — (See  Figs.  45  and  46,  pages  149  and  150.) 

Dr.  Stephen  Mackenzie  thinks  that  the  pressure  upon  the  veins  of 


TUMO  URS  OF  THE  CEREBELL  UM. 


195 


Galen  is  neither  the  sole  nor  the  essential  cause  of  dropsy  of  the 
ventricles.  He  says,  "  the  hydrocephalus  is  usually  ascribed  to 
pressure  on  the  veins  of  Galen,  which,  by  increasing  the  lateral 
pressure  on  its  radicles,  causes  exudation  of  their  fluid  contents,  in 
the  same  way  that  pressure  on  the  portal  vein  causes  ascites.  It  will 
be  readily  seen  from  the  diagram  (Fig.  67)  that  a  tumour  of  the 
cerebellum,  especially  of  its  middle  lobe — a  favourite  situation — will 
be  extremely  Hkely  to  compress  the  vense  Galeni.  But  I  beheve  that, 
whilst  this  may  be  a  contributory  factor  in  the  production  of  the 
hydrocephalus,  it  is  neither  the  sole  nor  essential  one.  Granting  that 
a  tumour  pressing  upon  the  veins  of  Galen  causes  dropsy  of  the 


Fig.  67. — Diagram  showing  the  manner  in  which  compression  of  the 
veins  of  Galen  is  produced  by  a  tumour  of  the  cerebellum,  more  especially 
of  its  middle  lobe.     (After  Stephen  Mackenzie.) 

The  letter  a  points  to  the  superior,  and  6  to  the  inferior  longitudinal 
sinus  ;  c  to  the  straight  sinus  ;  d  to  a  tumour  beneath  the  tentorium  ;  and 
e  to  the  veins  of  Galen. 


ventricles,  as  long  as  the  outlet  of  the  general  ventrical  cavity  remains 
patent,  as  the  fluid  collects  it  will  flow  away ;  moreover,  if  the  pres- 
sure be  extreme,  it  will  cause  obliteration  of  the  vein.  But  it  will  be 
readily  seen  by  reference  to  the  diagram  (Fig.  68)  that  subtentorial 
tumours,  especially  when  involving  the  middle  lobe,  will  be  extremely 
likely  to  cause  constriction  or  obliteration  of  the  cerebro- spinal 
foramen,  or  some  point  above  this — the  fourth  ventricle  or  aqueduct 
of  Sylvius.  .  .  .  Wlien  the  communication  between  the  general 
ventricular  cavity  and  the  subarachnoid  space  is  obliterated,  the  fluid 


196 


LOCAL  DLA GNOSIS. 


poured  out  by  the  choroid  plexuses,  and  possibly  the  obstructed  vence 
Galeni,  is  dammed  up,  distends  the  ventricles,  and  causes  the  extreme 
hydrocephalus  sometimes  found.  .  .  .  The  effects  of  this  dropsy 
of  the  ventricles  are  very  interesting  and  characteristic.  The  very 
gradual  and  equable  (water)  pressure  to  wliich  all  parts  of  the  brain 
are  subjected  causes  a  gradual '  blotting  out '  or  dissolution  of  what 
mental  faculties  have  been  obtained,  and  the  order  of  this  blotting 
out  is  very  instructive  to  the  psychologist.  From  a  conscious 
volitional  being,  the  patient  is  reduced  to  a  mere  automaton,  or  to  a 
vegetative  existence.  In  this  condition  he  may  continue  for  a  con- 
siderable time."  ^ 


Fig.  68. — Diagram  showing  the  manner  in  which  tumours  of  the  cere- 
bellum interrupt  the  communication  between  the  cavities  of  the  ventricles 
and  the  subarachnoid  space.     (After  Stephen  Mackenzie.) 

The  letter  a  points  to  the  tentorium  cerebelli ;  h  to  the  fourth  ventricle  ; 
c  to  the  cerebro-spinal  foramen. 

A  tumour  in  the  situation  of  the  cross  would  obliterate  the  cerebro-spinal 
foramen  ;  while  a  tumoiu-  a  little  above  the  point  marked  by  the  cross  might 
obliterate  the  cavity  of  the  fourth  ventricle. 

In  tubercular  cases,  and  indeed  in  other  forms  of  new  growth, 
when  the  case  is  of  long  duration,  there  may  be  considerable  emacia- 
tion. In  many,  but  by  no  means  in  all  cases  of  tubercular  tumour 
of  the  cerebellum,  there  is  evidence  of  tubercle  in  the  form  of 
enlarged  glands,  diseased  joints,  diseased  lungs,  &c.,  in  some  other 

1  Lancet,  vol.  i.,  1880,  p.  559. 


TUMOURS  OF  THE  CEREBELLUM.  197 

part  of  the  body.  In  some  cases  in  which  there  is  no  actual  mani- 
festation of  tubercle,  the  hereditary  history  is  so  strong  as  to  suggest 
that  the  cerebellar  lesion  is  scrofulous. 


77^6  Differmtial  Diagnosis  of  Cerebellai-  Tumour  and  Meniere  s  Disease. 

In  both  conditions,  vertigo  and  derangements  of  co-ordination  may 
be  marked  symptoms,  and  the  character  of  the  vertiginous  sensations 
and  of  the  ataxia  may  be  exactly  the  same.  The  cerebellum  would 
indeed  appear  to  be  the  centre  to  which  the  labyrinthine  nerves  pass, 
and  the  disturbances  which  result  from  irritation  or  destruction  of 
the  end-organ  (semicircular  canals)  are  necessarily  therefore  identical 
with  those  due  to  lesions  of  the  cerebellar  centres  themselves.  In 
both  conditions  there  may  be  vomiting,  and  in  both  convulsive 
twitchings. 

Though  in  these  respects  the  two  conditions  closely  resemble  one 
another,  the  distinction  can  as  a  rule  be  readily  made ;  for  in  the 
one  there  are  usually  symptoms  and  signs  of  a  central,  and  in  the 
other  of  a  peripheral  lesion. 

In  cerebellar  tumour,  marked  headache  and  double  optic  neuritis 
are  distinctive  symptoms,  and  there  may  be  evidences  of  motor 
paralysis  from  pressure  on  the  pons  Varolii  or  medulla  oblongata. 
Deafness  and  facial  paralysis  are  seldom  present. 

In  Meniere's  disease  there  is  no  marked  headache,  no  optic  neuritis, 
and  no  paralysis  of  the  limbs,  unless  the  condition  is  associated  with 
meningitis  or  some  other  cerebral  complication,  such  as  abscess,  which 
may  cause  these  symptoms.  While  signs  of  local  disease  of  the  ear 
(purulent  discharge,  &c.)  are  often  present,  there  is  usually  deafness 
or  some  other  alteration  of  hearing;  and  there  is  often  peripheral 
facial  paralysis,  due  to  involvement  of  the  facial  nerve  in  the  Fal- 
lopian canal. 

The  Differential  Diagnosis  of  Cerebellar  Tumour  and  Disseminated 
Cerebro-Spinal  Sclerosis. 

The  diagnosis  is  usually  easy,  but  in  some  cases  most  difficult.  In 
cerebellar  tumour,  headache   is  usually  much   more  severe  than  in 


198  DIAGNOSIS. 

cerebro-spinal  sclerosis.  Vomiting,  which  is  so  often  such  a  common 
symptom  in  cerebellar  tumour,  is  seldom  observed  in  cerebro-spinal 
sclerosis.  Double  optic  neuritis  is  usually  present  in  cerebellar 
tumour,  but  is  very  rarely,  if  ever,  met  with  in  cerebro-spinal  sclerosis. 
In  the  latter  affection  I  have,  however,  noticed  well-marked,  and  in 
one  case  apparently  post-neurotic,  optic  atrophy. 

The  characteristic  tremor  is  usually  much  greater,  and  is  developed 
at  a  much  earlier  stage  in  cerebro-spinal  sclerosis.  It  is  chiefly  in  the 
later  stages  of  cerebellar  tumour  that  the  pressure  on  the  pons  Varolii 
becomes  so  considerable  as  to  produce  this  symptom. 

Xystagmus  is  more  common  in  cerebro-spinal  sclerosis.  The 
peculiar  vacant  look,  and  the  characteristic  scranning  speech  of 
cerebro-spinal  sclerosis,  have  not,  so  far  as  I  know,  been  noticed  in 
cerebellar  tumour, 

A  careful  consideration  of  the  whole  progress  and  coui'se  of  the 
case,  together  with  the  special  symptoms  in  each  individual  instance, 
will  usually  enable  the  observer  to  differentiate  the  two  conditions 
without  much  difi&culty. 


CHAPTER    IX. 

PATHOLOGICAL  DIAGIJ^OSIS  AND  MOEBID  ANATOMY. 

The  determination  of  the  pathological  nature  of  the  tumour  is  in 
many  cases  a  matter  of  great  importance,  both  for  prognosis  and 
treatment ;  for,  although  in  the  present  position  of  science  the 
syphilitic  is  the  only  form  of  intracranial  tumour  which  can  with 
any  certainty  be  influenced  by  treatment,  it  is  possible  that,  in 
the  future,  we  may  be  able  to  restrain  the  growth  or  to  pro- 
duce the  absorption  and  complete  cure  of  intracranial  tumours  by 
means  of  internal  remedies  (drugs). ^  And  at  the  present  time  the 
determination  of  the  pathological  nature  of  the  tumour  is  of  great 
importance  from  the  operative  point  of  view.  No  one,  for  example, 
would  recommend  an  operation  for  the  removal  of  an  intracranial 
melanotic  sarcoma,  or  of  any  other  multiple  tumour,  such  as  secondary 
cancer.  The  removal  of  a  gliomatous  tumour,  too,  is  in  some  cases 
questionable,  on  account  of  the  diffuse  and  extensive  infiltration  which 
is  often  present  in  these  cases,  and  the  consequent  impossibility  of 
completely  removing  such  new  growths.  On  the  other  hand,  where 
there  is  reason  to  suppose  that  the  tumour  is  encapsuled  (such  a  form 
of  new  growth,  for  example,  as  an  encapsuled  sarcoma),  an  operation 
is  indicated,  provided  that  the  other  conditions  for  active  interference 
(see  page  246)  are  favourable. 

The  most  common  forms  of  new  growths,  which  are  found  within 
the  cavity  of  the  cranium,  are  scrofulous  and  syphilitic  tumours  ;  next 
in  order  of  frequency  come  giiomata,  and  the  various  forms  of  sar- 
coma ;  then,  but  a  long  way  behind,  cancers  and  endotheliomata ; 
lastly,  cysts  of  various  forms  (simple  and  parasitic) ;  psammomata, 
cholesteatomata,  neuromata,  fibromata,  osteomata,  lipomata,  melano- 
mata,  &c. 

^  Scrofulous  tumours  are  in  some  instances  materially  benefited  by  appropriate  treat- 
ment (see  p.  248) ;  and  in  some  cases  the  active  growth  of  sarcomata  is  apparently 
restrained  by  the  internal  administration  of  arsenic. 


200  PATHOLOGICAL  DIAGNOSIS. 

Scrofulous  tumours  are  the  most  common  form  in  young  people, 
^.e.,  below  the  cage  of  fifteen,  and  syphilitic  tumours  in  adults  between 
the  ages  of  twenty-five  and  fifty. 

In  some  cases  the  tumour  is  primary,  in  others  secondary.  The 
new  growth  may  originate  in  the  connective  tissue  of  the  brain  or 
its  membranes,  in  the  bones  of  the  skull,  in  the  pituitary  body  or 
pineal  gland ;  but,  with  perhaps  the  single  exception  of  the  rare  form 
which  is  termed  a  neuroma,  the  tumour  does  not  grow  from  the 
nervous  tissues  proper. 

Secondary  tumours  (deposits)  may  reach  the  brain  either  through 
the  blood-vessels  or  lymphatics,  and,  for  the  reasons  previously  given 
(see  page  3),  the  primary  new  growth  is  frequently  pulmonary. 

Various  degenerations  (such  as  the  myxomatous,  caseous,  and 
calcareous)  may  affect  intracranial  like  other  forms  of  new  growth. 

The  determination  of  the  pathological  diagnosis  is  in  some  cases 
easy ;  in  others  most  difficult  or  impossible.  Indeed,  in  many  cases 
the  pathological  diagnosis  is  rather  a  matter  of  probability  or  of 
numerical  chance,  than  of  logical  conclusion  based  on  definite  facts. 

In  trying  to  arrive  at  a  pathological  diagnosis  the  following  are 
the  most  important  points  to  which  attention  should  be  directed  : — 
(1.)  A  history  of  the  removal  of  a  ijrevious  neio  growth  of  hnowii  ixdho- 
logical  character,  or  the  ^presence  of  associated  new  growths  {of  known 
imthological  character)  in  some  other  part  of  the  tody. 

When  symptoms  of  a  cerebral  tumour  develop  some  months  after 
the  removal  of  a  pigmented  mole  or  melanotic  sarcoma,  the  diagnosis, 
both  that  there  is  a  tumour,  and  that  it  also  is  a  melanotic  sarcoma, 
is  of  course  self-evident.  So  again,  when  symptoms  of  a  cerebral 
tumour  develop,  and  a  sarcomatous  tumour  is  present  on  the  ribs  or 
sternum,  or  when  there  is  evidence  of  cancer  in  the  liver  or  a  history 
of  the  removal  of  a  cancerous  breast,  the  pathological  diagnosis  does 
not  require  to  be  sought  for,  for  it,  as  it  were,  declares  itself. 

(2.)  The  presence  of  symjjtoms  or  signs  of  some  dyscrasia,  diathesis, 
or  special  constitutional  condition  ivhich  p)redisposes  to  a  particular 
form  of  new  growth. 

The  presence  of  otlier  distinctly  syphilitic  lesions  (such  as  nodes 
on  the  exterior  of  the  skull  or  shins),  the  evidences  of  former 
syphilitic  lesions  (cicatrices  of  previous  ulcerations),  or  the  presence 


PATHOLOGICAL  DIAGNOSIS.  201 

of  a  marked  dyscrasia  (such  as  the  muddy,  unhealthy  complexion 
which  is  so  common  in  constitutional  syphilis),  would  of  course  be 
strongly  in  favour  of  the  (cerebral)  tumour  being  syphilitic.  So,  too, 
the  presence  of  enlarged  and  caseous  glands,  of  scrofulous  joint 
disease,  of  phthisis,  or  other  distinct  tubercular  manifestations,  would 
be  strongly  suggestive  of  the  scrofulous  character  of  the  new  growth. 

Again,  a  strong  hereditary  history  of  scrofula  in  a  child,  or  of 
cancer  in  an  old  adult,  would  suggest  that  in  the  former  the  cerebral 
tumour  was  scrofulous,  and  in  the  latter  cancerous.  The  diagnostic 
value  of  an  hereditary  tendency  to  a  particular  form  of  new  growth  is 
seldom,  however,  very  great. 

(3.)  The,  age  of  the  patient. — This  is  of  some  little  value.  Scrofulous 
tumours  are  by  far  the  most  common  form  of  new  growth  in  children. 
Syphilitic  tumours  are  practically  never  seen  in  children,  but  almost 
always  in  adults  ;  for  they  are  rarely,  if  ever,  the  result  of  inherited, 
but  are  almost  always  due  to  acquired  syphilis.  Grliomata  may  occur 
at  any  age,  and  so  may  sarcomata.  Cancers  are  almost  always  seen 
in  old  people. 

(4.)  Sex. — This  is  of  little  value.  Most  forms  of  cerebral  tumour, 
but  more  especially  syphilitic  growths,  are  more  common  in  males  ; 
but  the  fact  is  seldom  of  much  value  to  the  diagnostician. 

(5.)  A  history  of  injury. — The  fact  that  the  tumour  has  developed 
immediately  after  and  is  apparently  the  result  of  an  injury,  is,  I 
think,  suggestive  that  it  is  either  a  syphiloma,  a  sarcoma,  a  glioma,  or 
a  scrofulous  tumour. 

(6.)  The  situation  of  the  new  growth. — This  is  of  considerable 
diagnostic  value.  The  most  frequent  seat  of  scrofulous  tumours  is 
the  cerebellum.  Tumours  of  the  pons  Varolii  are  usually  either 
scrofulous,  gliomatous,  or  syphilitic.  Tumours  on  the  surface  of  the 
hemispheres  are  usually  either  syphilitic,  sarcomatous,  or  localised 
tubercular  deposits.  Primary  tumours  of  the  centrum  ovale  and 
corpus  callosum  are  usually  gliomata  or  sarcomata.  Tumours  at  the 
base  are  usually  enlargements  or  new  growths  of  the  pituitary  body, 
aneurisms  of  the  large  vessels,  syphilitic  gummata,  cancers,  or  sarcomata. 

(7.)  The  style  of  the  symptoms,  and  the  manner  of  their  development, 
the  duration  of  the  case,  and  the  effects  of  special  modes  of  treatment. — 
These  are  all  of  some  diagnostic  importance. 


202  PATHOLOGICAL  DIAGNOSIS. 

The  presence  of  symptoms  indicative  of  several  separate  lesions  is 
suggestive  of  syphilis,  or  of  some  secondary  form  of  tumour  (scrofu- 
lous, melanotic  sarcoma,  cancer,  &c.). 

Jacksonian  epilepsy  is  suggestive  of  a  cortical  lesion,  and  more 
especially  of  syphilis  or  tubercle. 


Fig.  69. — Enlargement  of  the  head  in  a  case  of  so-called  perforating 
tumour  of  the  dura  mater.     (After  Drummond.) 


Pseudo-apoplectic  attacks  are  suggestive  of  syphilis  or  glioma. 
True  apoplectic  attacks,  followed  by  lasting  paralysis,  are  suggestive 
of  hcemorrhage  from  a  glioma,  but  they  may  be  due  to  syphilitic 
disease  and  plugging  of  a  large  vessel. 


PERFORATING   TUMOURS  OF  THE  DURA  MATER.  203 

Perforation  of  the  bones  of  the  skull  (such  as  is  represented  in  Figs. 
69,  70,  and  71)  only  occurs,  so  far  as  I  know,  in  sarcomata  and  cancers. 


J 


\^'\. 


■\^ 


^^ 


%- 


Fig.  70. — A  section  through  the  left  and  smaller  half  of  the  skull,  and  new  growth  in 
the  case  of  perforating  tumour  of  the  skull,  represented  in  Fig.  69.     (After  Drummond.) 

The  section  was  made  just  to  the  right  of  the  falx  ;  the  right  hand  side  of  the  figure 
corresponds  to  the  frontal  end. 

The  case  illustrated  in  Figs.  69  and  70  is  reported  by  Dr.  D.  Drummond  in  the  British 
Medical  Journal,  October  20,  1883,  page  762. 

The  patient,  a  boy,  aged  five,  was  admitted  to  the  Children's  Hospital,  Newcastle-on- 
Tyne,  on  December  5,  1882,  under  the  care  of  Dr.  Baumgartner,  suffering  from  headache, 
vomiting,  and  double  optic  neuritis.  There  was  also  a  swelling  on  the  right  side  of  the 
head  near  the  vertex.  This  swelling  rapidly  increased  in  size  until  the  head  measured  at 
the  point  of  greatest  circumference  above  the  ears  twenty-six  inches,  and  presented  the 
appearance  shown  in  Fig.  69.  The  right  eye  became  involved  and  destroyed  by  the 
new  growth  ;  other  tumours  developed  in  the  lower  jaw  and  testicle. 

The  patient  died  on  March  21,  1883.  At  the  post-mortem  examination  the  tumour 
was  removed  with  the  brain  and  most  of  the  cranium,  leaving  the  scalp  attached  to  a  portion 
of  the  base  of  the  skuU,  including  the  face.  The  tumour  mass  covered  the  right  frontal, 
right  parietal,  and  part  of  the  occipital  bones,  and  extended  over  the  middle  line  to  the  left 
side  for  about  four  inches,  so  as  to  involve  a  considerable  portion  of  the  left  parietal  and 
frontal  bones.  The  right  frontal,  and  portions  of  the  right  parietal  bone,  were  much 
thickened,  and  in  places  so  softened  and  infiltrated  with  the  new  growth  as  to  admit  of  the 
ready  passage  of  the  knife  through  the  tumour  into  the  brain  beneath.  The  surface  of  the 
mass,  after  the  skin  was  removed,  presented  a  peculiar  piebald  appearance,  being  princi- 
pally of  a  deep  red  colour,  with  patches  of  yellow  and  pink.  The  right  frontal,  parietal, 
and  temporo-sphenoidal  lobes  of  the  brain  were  much  compressed,  and  masses  of  soft,  red, 
cancer-like  new  growths  were  attached  to  the  cortex  of  the  upper  and  posterior  part  of 
the  first  temporo-sphenoidal  convolution,  the  supra-marginal  and  angidar  gyri,  and  part  of 
the  occipital  lobe.  On  making  a  longitudinal  section  through  the  tumour  and  skull,  the 
structure,  which  was  soft  and  elastic,  was  seen  to  be  of  a  deep  red  colour,  presenting  a 
highly  hsemorrhagic  appearance,  especially  the  portion  between  the  dura  mater  and  the 
inner  surface  of  the  cranial  vault. 

The  whole  thickness  of  the  tumour  was  about  two  inches,  of  which  nearly  three-quarters 
of  an  inch  lay  beneath  the  skull.  The  tumour  was  firmly  adherent  to  the  external  surface 
of  the  dura  mater,  which  it  pierced  in  places.  Here  and  there  the  tumour-mass  was  studded 
with  long  spiculse  of  bone  ;  or,  to  be  more  accurate,  the  tumour  tissue  had  invaded  the 
bones,  expanding,  softening,  and  at  the  same  time  thoroughly  infiltrating  them. 

On  microscopical  examination  the  tumour  was  found  to  be  a  highly  vascular,  small 


204 


FA  THOL  O  GICA  L  DIA  GNOSIS. 


In  cases  of  cerebral  syphilis,  the  symptoms  usually  develop 
quickly,  and  often  subside  rapidly  under  large  doses  of  iodide  of 
potassium  and  mercury. 

Gliomatous  tumours  are  often  of  very  long  duration,  and  so  are 
many  encapsuled  sarcomatous  tumours  growing  from  the  membranes. 


Fig.  71. — Perforating  tumour  of  the  dura  mater.     (After  Drummond.) 
The  case  is  reported  in  the  British  Medical  Journal,  October  20,  1883, 
page  763. 

In  such  cases  tlie  general  symptoms  may  be  characteristic  of  tumour, 
but  localising  symptoms  are  often  wanting. 

Some  other  points  of  a  similar  nature  might  be  mentioned,  but 
they  will  perhaps  be  better  described  in  connection  with  the  special 
features  of  each  form  of  new  growth,  to  which  we  must  now  proceed. 


The  Scrofulous  Tumour. 

Tubercular  tumours  are  the  most  common  form  of  new  growth  in 
young  people.     The  cerebellum  is  the  most  frequent  seat,  but  the  pons 


TUBERCULAR  TUMOURS. 


205 


Varolii  and  cerebrum  (both  cortex  and  basal  ganglia)  are  frequently- 
affected.  In  some  cases  the  tumour  is  single,  in  others  multiple.  I 
have  seen  as  many  as  eight  separate  scrofulous  nodules  in  different 
parts  of  the  same  brain. 


Fig.  72. — Right  hand  of  a  patient  suffering  from  ophthalmoplegia 
externa  acuta,  which  was  probably  due  to  a  tubercular  lesion  at  the  top  of  the 
pons  Varolii,  showing  scrofulous  enlargement  of  the  middle  finger.  (Copied 
from  a  photograph. ) 

Other  tubercular  lesions,  such  as  enlarged  caseous  glands,  scro- 
fulous disease  of  the  bones  or  joints  (see  Fig.  72),  phthisis,  &c.,  are 
very  generally  present,  but  are  not  always  detectable  before  death.  In 
all  cases  of  scrofulous  brain  tumour  there  is  probably  some  source  of 
local  infection  ;  a  very  common  one,  which  is  often  unsuspected 
during  life,  is  a  caseous  mesenteric  gland. 

In  many  cases  tubercular  meningitis  is  developed  in  association 
with  scrofulous  tumours  of  the  brain  or  cerebellum  ;  and  the  clinical 
picture  may  for  this  reason  be  complicated. 


2o6 


PATHOLOGICAL  DIAGNOSIS. 


The  scrofulous  tumour  varies  in  size  from  the  smallest  possible 
nodule  up  to  a  large  mass  as  big  as  a  turkey's  egg.  The  form  of 
the  tumour  is  generally  more  or  less  rounded;  the  consistency  is 
usually  hard,  though  there  may  be  softening,  or  even  the  formation  of 
a  cavity  filled  with  broken-down  debris  in  the  centre  of  the  mass. 
The  colour  is  yellow  or  rather  greenish-yellow.  The  tumour  is 
developed  in  the  substance  of  tlie  nerve  tissue,  and  in  this  respect 


Tig.  73. — Large  scrofulous  tuinoiir  of  the  right  lobe  of  the  cerebellum. 
Copied  from  a  photograph  (reduced  in  size). 

The  letter  D  points  to  the  tumour,  to  the  outer  surface  of  which  the  dura 
mater  is  adherent  (the  line  passing  from  the  letter  D  to  the  tumom*  crosses 
the  dura,  which  has  been  partly  turned  back  off  the  tumour). 

The  left  lobe  of  the  cerebellum  is  natural,  and  forms  a  remarkable  con- 
trast as  regards  size  to  the  corresponding  part  on  the  opposite  side. 

presents  a  marked  difference  from  most  syphilitic  tumours,  which 
may  easily  enough  be  confounded  with  it.  The  nervous  tissue 
around  the  tumour  is  usually  softened  or  inflamed.  The  membranes 
over  the  surface  of  the  tumour  are  in  many  instances  adherent  to 
the  affected  portion  of  brain  tissue  (see  Fig.  73,  in  which  the  dura 
mater  is  firmly  adherent  to  the  left  lobe  of  the  cerebellum,  in 
which  a  large  scrofulous  tumour  is  situated).  A^Tien  the  scrofulous 
tumour  reaches  the  surface,  it  may  extend  by  direct  contiguity  from 
one  portion  of  the  brain  to  another.  I  have  seen  a  scrofulous  tumour 
extend  in  this  way  directly  from  the  surface  of  the  left,  to  the  surface, 


TUBERCULAR  TUMOURS. 


207 


and  thence  to  the  interior,  of  the  right  lobe  of  the  cerebellum.     In 
some  cases  the  tumour  becomes  calcified. 


Fig.  74. —  Giant  cells  from  the  scrofulous  tumour  of  the  pons  Varolii, 
shown  in  Fig.  64,  page  185.  H,,  oc.  3,  obj.  8,  tube  out,  and  drawing 
reduced  one-third. 


Fig.  75. — Camera  lucida  drawing  of  a  transverse  section  through  a  portion 
of  the  scrofulous  tumour  of  the  pons  Varolii,  shown  in  Fig.  64.  Stained 
with  picro-carmine ;  magnified,  oc.  3,  obj.  8,  tube  out ;  and  drawing  reduced 
from  \\  to  3  inches. 

The  letter  B  points  to  a  dense  cellular  infiltration  in  the  coats  of  the 
blood-vessel ;  4,  to  a  similar  infiltration  in  the  surrounding  cellular  tissue  ; 
B,  to  large  cells  in  the  surrounding  tissue  ;  and  C,  to  the  junction  of  the 
tumour  with  the  normal  tissue  of  the  pons. 

On  microscopical  examination  the  usual  characteristics  of  a  scrofu- 
lous lesion  are  found  (giant  cells,  and,  with  satisfactory  methods  of 


2o8  PATHOLOGICAL  DTAGNOSLS. 

preparation,  tubercle  bacilli).  Fagge  thinks  tliat  the  cells  which 
surround  scrofulous  tumours  of  the  brain  are  larger  than  the  cells 
found  in  tubercle  in  other  organs.  The  microscopic  appearances 
characteristic  of  the  scrofulous  tumour  are  well  seen  in  Figs.  74  and  75. 

The  diagnostic  features  of  the  scrofulous,  t^imour  are  often  suffi- 
ciently characteristic  to  enable  a  positive  opinion  as  to  the  nature  of 
the  tumour  to  be  given. 

By  far  the  most  important  fact  is  the  presence  of  tubercle  in  some 
other  part  of  the  body,  or  cicatrices  in  the  neck  or  other  evidences  of 
former  scrofula.  Failing  positive  evidence  of  this  kind,  the  peculiar 
build  of  the  thorax  and  body  generally,  which  we  know  from  experience 
is  apt  to  be  associated  with  phthisis ;  a  strong  hereditary  history  of 
scrofula ;  the  fact  that  the  patient  is  a  child,  or  at  all  events  young ; 
that  the  tumour  is  situated  in  the  cerebellum;  that  the  general 
health  is  (in  some  cases  at  all  events)  considerably  affected ;  and  that 
there  is  no  evidence  to  show  that  the  tumour  is  syphilitic,  sarcomatous, 
&c.,  are  the  most  important  points.  It  should  further  be  remembered 
that  in  some  cases  a  head  injury  seems  to  be  the  exciting  cause  of 
this  form  of  new  growth. 

The  Syphilitic  Tumour. 

This  is  the  most  common  form  of  new  growth  in  adults  (between 
the  age  of  twenty-five  and  fifty),  but  is  very  seldom  seen  in  younger 
persons  or  children ;  for  it  is  almost  always  the  result  of  acquired 
syphilis,  and  is  very  rarely  indeed  due  to  the  inherited  form  of  the 
disease.  Dr.  Wood  has  "  seen  cerebral  syphilis  occur  at  twenty 
years  of  age  as  the  first  evident  outbreak  of  inherited  syphilis ; "  but 
this  is  quite  exceptional.  ^ 

In  males,  a  history  of  primary  syphilis  can  usually  be  elicited.  It 
is  important  to  remember  that  in  many  cases  in  which  cerebral 
syphilis  subsequently  develops,  the  secondary  symptoms  are  slight, — 
in  fact,  they  may  be  so  insignificant  as  to  escape  attention.  The 
length  of  time  which  elapses  between  the  primary  chancre  and  the 
development  of  cerebral  symptoms  is  very  variable,  but  is  usually 
several  years.     Cases  have,  however,  been  recorded  in  which  cerebral 

^  Pepper's  System  of  Medicine,  vol.  v.,  p.  1007. 


SYPHILITIC  TUMOURS.  209 

symptoms  seem  to  have  developed  within  a  few  months  of  infection.  In 
some  cases,  injury  to  the  head  appears  to  be  the  exciting  cause  of  this 
form  of  tumour. 

The  intracranial  lesions  which  may  result  from  syphilis  are 
numerous.  The  most  important  are — (1.)  Intracranial  nodes,  with 
or  without  meningitis.  (2.)  Gummata.  (3.)  Syphilitic  lesions  of 
the  large  or  medium-sized  vessels  (chiefly  endarteritis  obliterans), 
the  result  of  which  is  diminished  or  arrested  blood  supply  to 
well-defined,  and  in  some  cases  extensive,  areas  of  the  brain  tissue, 
with  the  consequent  production  of  well-defined,  naked- eye  lesions, 
such  as  softenings.  (4.)  Localised  inflammation  (cerebritis)  or 
softening  in  the  neighbourhood  of  gummata  and  meningeal  lesions. 
(5.)  Inflammation  of  the  intracranial  peripheral  nerves.  In  cases 
of  this  kind,  the  inflamed  nerve  is  usually  infiltrated  by  a  gum- 
matous deposit;  but  it  is  probable  that  syphilitic  neuritis  may  be 
present  without  gumma  or  meningitis.  (6.)  Meningeal  inflammations 
without  gummatous  deposits.  Whether  syphilis  does  produce  a  more  or 
less  generalised  inflammation  of  the  soft  membranes,  which  may  result 
in  adhesion  of  those  membranes  to  the  surface  of  the  brain,  without 
localised  gummatous  deposits  or  other  well-marked  syphilitic  lesions, 
is  doubtful.  (7.)  Disease  of  the  minute  vessels  (in  many  instances 
periarteritis,  I  believe,  rather  than  endarteritis  obliterans),  with 
resulting  minute  changes  in  the  cerebral  cortex— atrophy  or  slow 
destruction  of  the  nerve  elements,  increase  of  the  connective  tissue, 
and  a  final  condition  of  sclerosis  and  atrophy  of  the  grey  matter. 

Now  in  most  cases  of  intracranial  syphilis,  although  one  form  of 
lesion  may  predominate,  or  appear  to  predominate,  the  other,  or  some 
of  the  other  forms  of  lesion  described  above  are  usually  present  in 
some  degree.  Possibly  any  one  of  these  lesions  may  be  present  alone 
or  in  combination  with  any  other. 

The  form  of  cerebral  syphilis  with  which  we  are  here  specially 
concerned  is  the  syphilitic  tumour  or  gumma.  In  the  vast  majority 
of  cases  it  is  situated  on  the  surface  of  the  brain  (see  Figs.  76,  77,  and 
82),  very  often  in  the  frontal  or  Eolandic  areas,  or  at  the  base.  I 
have,  however,  met  with  two  cases  in  which  a  syphilitic  gumma  was 
situated  in  the  substance  of  the  brain  (see  Fig.  79). 

More  or  less  meningitis  is  almost  always  found  in  the  immediate 


2IO  PATHOLOGICAL  DIAGNOSIS. 

neighbourhood  of  the  gumma,  and  in  many  cases  the  meningeal  in- 
flammation is  the  most  striking  feature  of  the  case  (see  Fig.  76). 

The  lesion  gradually  invades  the  brain  substance,  and  this  process 
of  invasion,  which  is  well  represented  in  Figs.  77,  78,  and  80,  is  attended 
both  clinically  (during  life)  and  microscopically  (after  death)  with 
striking  evidences  of  irritation. 


Fig.  76. — Transverse  vertical  section  through  the  left  hemisphere  of  the 
brain  (frontal  region  and  tip  of  the  temporo-sphenoidal  lobe)  in  a  case  of 
gummatous  syphilis.     (Seen  from  behind.) 

The  dura,  to  which  the  letter  E  points,  is  thickened  and  adherent ;  the 
letter  F  points  to  the  gummatous  and  inflammatory  products  situated  be- 
tween the  membranes  and  the  surface  of  the  brain ;  the  letter  G  to  the  surface 
of  the  brain,  at  a  point  where  it  is  being  invaded  by  the  syphilitic  lesion. 

Another  most  important  feature  of  the  syphilitic  gumma,  from  a 
clinical  point  of  view,  is  the  fact  that  the  nerve  trunks  and  vessels  in 
its  neighbourhood  are  apt  to  be  involved  and  infiltrated  by  the  lesion 
(see  Figs.  82  and  86). 


SYPHILITIC  TUMOURS, 


211 


In  many  cases  there  are  several  syphilitic  lesions  in  the  same 
brain— see  Figs.  81,  82,  and  83,  in  which  an  enormous  softenino-,  due 


B 


Fig.  77.— Camera  lucida  drawing  of  a  microscopical  section  through  the 
niembranea  and  cortex  of  the  brain  in  a  case  of  syphilis;  showing  thickening 
of  the  membranes  {B  and  U),  with  gummatous  products  (C)  between  them  • 
and  mvasion  of  the  superficial  portion  of  the  cortex  cerebri  {E).  Low  power— 
Hartnack,  oc,  3,  obj.  1  ;  and  drawing  reduced  from  7i  to  6i  inches. 


212  PATHOLOGICAL  DLAGNOSLS. 

to  syphilitic  arterial  disease,  was  associated  with  a  well-marked  gumma, 
meningitis,  and  involvement  of  the  third,  optic,  and  other  nerves. 
The  naked-eye  appearances  which  the  sj'philitic  gumma  presents, 

'k  :'  '  "-    P    ■       \:  -    '■'    ^   '-  '      ■■■■.    ^ 


& 


\  .    .'         -  ^--^ 


0    p 


'i^lt' 


:s-; 


?;■ '"  ' 


y.^ 


Is' 


'i^iilSS-iSie^.Ka^C;';- 


FiG.  78. — Camera  lucida  drawing  of  a  portion  of  a  microscopical  section 
througli  the  deeper  layers  of  the  greatly  thickened  pia  mater  (^-1 )  and  the 
superficial  portion  of  the  cortex  cerebri  in  a  case  of  syphilitic  disease. 
Hartnack,  oc.  3,  obj.  4  ;  drawing  reduced  from  51  to  4  inches. 

B,  junction  of  pia  and  cortex  ;  C,  diseased,  and  E,  comparatively  healthy 
cortex  ;  D,  diseased  vessel. 

cannot  be  better  described  than  in  the  words  of  Heubner.  He  says, 
"  The  most  frecjueut  change  met  with  in  the  cranium  of  patients,  who 
develop  cerebral  disease  under  the  influence  of  syphilitic  cachexia,  is 
the  formation  of  a  heteroplastic  tissue,  the  s}^hiloma  or  gummous 
tumour.  "We  shall  therefore  describe  it  first.  The  new  growth  ap- 
pears in  two  very  different  forms,  which,  however,  are  often  united  in 
the  same  body,  either  (first)  as  a  whitish  or  greyish-red  or  moist  gTcy 
mass,  of  the  consistency  of  a  firm  jelly,  in  thinner  places  half  trans- 


SYPHILITIC  TUMOURS. 


213 


lucent ;  of  irregular  form,  generally  determined  by  the  place  where  it 
is  seated  ;  discharging  upon  its  cut  surface  a  scanty  whitish-red  juice, 
and  gradually  blending  with  the  surrounding  tissues ;  or  (second)  as 


r  I 

1 


''4- 


Iff  ^'^ .  '- 


t-'f'i ,- 


s>=" 


|i 


-^ 


Fig.  79. — Camera  lucida  drawing  of  a  microscopical  section  through  the 
pons  Varohi,  sho^ving  a  syphilitic  gumma  {A )  in  its  interior.  Hartnack, 
oc.  2,  obj.  1  ;  and  drawing  reduced  from  6^  to  4|  inches. 

A,  gumma ;  B,  diseased  vessel  on  surface  of  pons  ;  C,  bundles  of  the 
pyramidal  tract  ;  D,  substance  of  pons  surrounding  gumma.  There  is,  it 
will  be  observed,  no  meningitis. 

a  yellow,  firmer — often  as  firm  as  cartilage — dry,  friable  substance, 
upon  section  homogeneous  and  cheesy,  which  is  found  either  in  the 
form  of  somewhat  sharply  circumscribed  larger  or  smaller  tumours,  or 


2  14  -PA  THOL  0 GICAL  DIA  GNOSIS. 

invading  the  greyish-red  substance  just  described,  sometimes  as  larger 
nodules  and  streaks,  and  sometimes  as  a  more  minute  marbling. 

"  The  greyish-red  mass  consists  chiefly  of  round  cells,  with  a  small 
proportion  of  nuclei,  and,  among  them,  spindle  and  stellate  cells, 
arranged  sometimes  apparently  without  order,  and  sometimes  forming 
groups  together  with  an  alveolar  framework.  These  cell  masses  lie, 
as  far  as  possil)le,  in  the  interstices  of  the  original  tissue,  the  consti- 
tuents of  which,  altered  or  not,  form  the  chief  part  of  the  intercellular 
substance  of  the  new  growth,  which  is  permeated  by  scanty  capillaries, 

A 


Fig.  80. — Camera  lucida  drawing  of  a  microscopical  section  through  a 
syphilitic  gumma  of  the  brain,  showing  enlarged  connective  tissue  cells  (C 
and  D),  and  infiltration  of  the  intervening  tissue  with  corpuscular  ele- 
ments {E).  Hartnack,  oc.  3,  obj.  8,  tube  out  ;  and  drawing  reduced  from  4 
to  3  inches. 

A  transversely,  and  B  longitudinally  divided  vessels. 

often  of  large  calibre.  Hence  in  places  where  the  original  tissue  was 
delicate  and  contained  much  water,  the  growth  is  softer  (subarachnoid 
space) ;  where  it  was  more  dense  and  fibrous,  firmer  (dura  mater). 
AAliere  the  interstices  of  the  tissue  are  large,  there  numerous  cells  lie 
together  in  large  alveolar  spaces,  which  may  be  again  divided  into 
secondary  spaces  by  finer  fibres  (Wagner);  where  the  meshes  are 
small,  only  a  few  cells  lie  in  nan'ow  fissures.  In  the  first  case  we 
have  to  do  with  a  growth  rich  in  cells ;  in  the  latter,  with  one  more 
fibrous  and  brawny.     The  source  of  the  chief  mass  of  the  cells  is 


SYPHILITIC  TUMOURS. 


215 


probably  to  be  found  in  the  blood ;  the  granulation  cells  have  mostly 
emigrated ;  the  spindle  cells,  which  in  many  places  are  arranged  in  a 
more  organised  structure,  as  young  connective  tissue,  in  the  meshes 
of  which  round  cells  lie,  probably  arise  from  the  connective  tissue 
strata  of  the  place  at  which  the  growth  originated.  One  can  often 
observe  how  the  same  growth,  which  in  one  place  has  the  character 
of  indifferent  granulation  tissue  (for  instance,  in  the  subarachnoid 
space),  upon  reaching  another  tissue  (for  instance,  brain  substance), 
immediately  assumes  an  exquisite  alveolar  structure.     In  tumours  of 


Fig.  81. — Transverse  vertical  section  through  the  frontal  lobes  of  the 
brain,  just  in  front  of  the  tip  of  the  temporo-sphenoidal  lobe,  in  a  case  of 
cerebral  syphilis ;  sho's^ing  an  extensive  softening  of  the  right  hemisphere, 
the  result  of  syphilitic  disease  of  the  nutrient  vessels.  Facsimile  repre- 
sentation of  a  photograph  (reduced  in  siz-e). 

The  softening,  it  will  be  noticed,  extends  for  some  little  distance  across 
the  corpus  callosum. 

the  subarachnoid  space,  the  mass  of  cells  lies  embedded  in  a  gelatinous 
intercellular  substance  within  the  meshes  of  connective  tissue. 

"  The  whole  new-formed  tissue  is  permeated  by  blood-vessels, 
chiefly  of  a  capillary  character,  which  are  more  or  less  abundant 
according  to  their  abundance  in  the  original  structure ;  in  some  places 
little  extravasations  may  be  found,  which  mark  the  cut  surface  of 


2l6 


FA THOLOGICAL  DIA GNOSIS. 


the  new  growth  with  reddish  points.  Many  of  these  blood-vessels, 
especially  the  smallest,  possess  a  much-thickened  wall  (perithelium). 

"  This  form  of  tumour  is  never  sharply  defined ;  on  examining  the 
edges  by  the  microscope,  one  may  see  at  points  apparently  normal  a 
strongly  marked  cellular  infiltration,  which  gradually  passes  into  the 
healthy  tissue. 

"  The  yellow  mass  is  found  first  in  the  form  of  veins,  streaks,  or 
so  that  one  or  several  yellow  dry  nodules  surrounded  by  the  greyish- 
red   substance   project  into  the   structure  just  described.      This  is 


Fig.  82. — Transverse  vertical  section  through  mid-region  of  the  brain  in 
a  case  of  cerebral  syphilis,  showing  a  gumma  invohdng  the  right  optic  nerve 
and  adjacent  portions  of  the  brain  tissue,  with  extensive  softening  and  disease 
of  almost  the  whole  transverse  section  of  the  right  hemisphere. 

The  letter  0  points  to  the  enormously  swollen  right,  and  P  to  the  com- 
paratively normal  left  optic  nerve. 

From  a  photograph  (reduced  in  size). 

particularly  frequent  where  the  new  growth  passes  into  nerve  tissue, 
or  is  chiefly  situated  therein.  It  then  consists  either  (1)  of  a  dry, 
somewhat  shining  fibrous  substance,  appearing  in  thick  sections, 
under  the  microscope,  gTey  or  greyish-yellow,  the  origin  of  which 
cannot  with  certainty  be  determined,  but  which  may  be  in  some  cases 


SYPHILITIC  TUMOURS. 


217 


the  remains  of  the  original  tissue  compressed  by  the  new  growth 
(atrophic  neuroglia),  and,  in  others,  masses  of  atrophic  cells  of  the 
neoplasm  itself ;  or  (2) — especially  in  nerve  sheaths,  in  the  tissue  of 
the  dura  mater,  in  the  larger  dry  masses — of  cells,  round  or  spindle- 
shaped  in  a  state  of  fatty  degeneration,  that  is,  masses  of  granule 
cells,  which  are  situated  in  large  agglomerations  within  the  meshes  of 
the  original  tissue. 

"  Secondly,  we  find  them  in  the  form  of  completely  circumscribed, 
often   almost  encapsuled  tumours  (like   cerebral  tubercles),  around 


Fig.  83. — Transverse  vertical  section  through  the  occipital  lobes  of  the 
brain,  in  a  case  of  cerebral  syphilis,  showing  extensive  softening,  involving 
the  whole  of  the  transverse  section  of  the  right  hemisphere. 

The  letter  K  points  to  a  large  softened  cavity  in  the  interior  of  the  right 
hemisphere  ;  the  letter  L  to  the  corpus  callosum  on  the  left  (healthy)  side. 

From  a  photograph  (reduced  in  size). 

which  remains  of  chronic  inflammation,  or  the  grey-red  new  formation 
may  be  found.  They  are  as  large  as  an  almond  or  dove's  egg,  and  in 
the  first  case  several  often  lie  together.  Their  form  is  not  infre- 
quently determined  by  the  space  in  which  they  are  seated  (fissures 
between  cerebral  convolutions),  behaving  thus  simply  like  a  caseous 
inflammatory  exudation.  Upon  microscopic  examination  it  seems 
that  this  homogeneous  mass  consists  of  a  granular  substance,  entirely 


2l8 


PATHOLOGICAL  DIAGNOSIS. 


uniform  upon  thin  sections,  apparently  without  further  structure,  and 
completely  devoid  of  vessels.  Wlien  broken  up  or  torn  apart,  how- 
ever, it  sets  free  for  the  first  time  a  multitude  of  angular  or  roundish 
granular  elements,  which  resemble  shrivelled  or  broken  cells  of 
roundish  shape,  and  may  correspond  very  well  to  the  remains  of  the 
round  cells  which  form   the   greyish-red  syphiloma.     Of  the  other 


Fig.  84. — Camera  lucida  drawing  of  a  microscopical  section  through  a 
syphilitic  gumma  at  the  base  of  the  brain,  showing  numerous  vessels  {A,  B, 
0,  D,  E),  the  walls  of  which  are  greatly  thickened,  and  many  of  which  ai-e 
entirely  obliterated  by  syphilitic  endarteritis.  Hai'tnack,  oc.  2,  obj.  1  ;  and 
drawing  reduced  from  4|  to  Z\  inches. 

G,  bundles  of  the  third  nerve  ;  A,  large  artery  transversely  divided,  its 
inner  coat  is  slightly  thickened ;  B,  small  artery  in  longitudinal,  and  C,  D, 
and  E,  small  arteries  in  transverse  section,  showing  extreme  endarteritis 
obliterans.  Most  of  these  small  vessels  are  completely  obliterated  by  the 
thickening  of  their  inner  coat.  The  minute  details  of  the  lesion  cannot  of 
course  be  made  out  under  this  low  power. 

The  letter  F  points  to  the  inflammatory  (gummatous)  material  in  which 
the  obliterated  (and  newly  formed)  vessels  lie. 

elements,  connective-tissue  fibres,  spindle  cells,  &c.,  nothing  more  is 
to  be  seen.  Here  and  there  lie  groups  of  needle-shaped  crystals  of 
fat,  with  granules  and  crystals  of  blood  pigment  intermixed,  while 
nearer  the  edges  of  the  yellow  growth  may  be  found  upon  section 
masses  of  fatty  granulation  cells.  The  chief  part  of  the  process,  however, 
here  does  not  consist  in  fatty  degeneration,  but  in  genuine  cellular 
atrophy  (caseification,  tubercularisation,  in  the  French  sense).     In  the 


SYPHILITIC  TUMOURS. 


219 


interior  such  tumours  are  perfectly  dry,  or  some  small  spots  of  soften- 
ing may  be  found.  The  surrounding  tissue  always  shows  a  recent, 
tolerably  vascular,  proliferating  cell-mass,  like  that  which  we  find  in 
general  in  the  greyish-red  growth ;  and  even  where  such  a  mass  is 
encapsuled  (which  is  always  the  case  with  the  tumours  situated  in  the 
dura  mater),  the  meshes  of  the  connective  tissue  forming  the  capsule 
are  infiltrated  with  young  cells. 

E 

<2. 


Fig.  85. — Camera  lucida  drawing' of  a  microscopical  section  through  a 
vessel  in  a  case  of  cerebral  syphilis,  showing  great  infiltration  and  thicken- 
ing of  the  outer  coat  (5),  and  an  organising  thrombus  [E)  in  its  interior. 
Hartnack,  oc.  3,  obj.  8,  tube  out ;  and  drawing  reduced  from  4|  to  3^  inches. 

A,  inflammatory  products  round  vessel  ;  B,  outer  ;  C,  middle  ;  and  D, 
inner  coats  ;  E,  organised  thrombus,  containing  delicate  new-formed  vessels 
in  its  interior. 

"  It  is  probable,  if  not  yet  strictly  proved,  that  these  yellow  tumours 
originate  in  the  greyish-red,  and  represent  the  dead  and  atrophied 
remains  of  the  younger  soft  tissue. 

"  This  neoplasm  in  its  various  forms  has  an  entirely  different  sig- 
nification, and  even  certain  anatomical  peculiarities,  according  to  the 
locality  within  the  cranial  cavity  in  which  it  is  developed. 


PATHOLOGICAL  DIAGNOSIS. 


"  It  has  two  favourite  seats :  the  dura  mater  and  the  subarach- 
noid space. 

"  Tlie  growth  very  frequently  affects  the  dura  mater  alone,  without 
the  participation  of  any  other  tissue  in  the  cranial  ca^aty.  It  then 
I)  B  C 


5>-?v-  ^i 


^-i.-t 


r  '--"J^     •^ 


^>--  ^ 


'A 

Fig.  86. — Camera  lucida  d^a^viIlg  of  a  microscopical  (longitudinal)  section 
througli  a  bundle  of  the  tMrd  nerve  in  cerebral  sj'philis,  showing  the  nerve 
tissue  entirely  destroyed,  and  the  nerve  infiltrated  with  cellular  elements. 
Hartnack,  oc.  2,  obj.  3  ;  and  drawing  reduced  from  4i  to  4  inches. 

A,  B,  free  surfaces  of  nerve  ;  C,  B,  masses  of  cells  in  nerve. 

develops  between   the  two  (greatly  thickened)  layers  of  the   dura 
mater,  and  is  beautifully  encapsuled  thereby. 

"  The  soft  greyish-red  growth  is  almost  never  met  wdth  in  this 
place,  but  either  the  fibrous  modification  of  the  cellular  neoplasm,  or, 


SYPHILITIC  TUMOURS.  221 

most  frequently,  the  dry,  yellow  tumour,  which  may  attain  the  size  of 
a  dove's  or  even  a  hen's  egg.  It  may  be  developed  in  any  region  of 
the  dura  mater,  hut  grows  particularly  large  in  the  duplicatures,  such 
as  the  falx,  &c. 

"  One  frequently  meets  with  smaller,  recent,  but  yet  firm  tumours 
in  the  dura  mater  overlying  the  sphenoid  bone.  In  such  cases  the 
membrane  is  thickened  around  the  tumour  and  for  some  distance  in 
the  neighbourhood,  and  the  interstices  of  the  connective  tissue  infil- 
trated with  rows  of  round  cells ;  the  part  of  the  cranial  bones  corre- 
sponding to  the  tumour  is  subject  to  the  so-called  caries  sicca,  is  rough 
and  eroded ;  the  rest  of  the  cerebral  contents  are  normal."  ^ 

The  naked-eye  and  microscopical  characters  of  the  gumma  and 
other  syphilitic  lesions  of  the  nervous  tissues  are  well  represented 
in  Figs.  76-86. 

Diagnostic  characters  of  the  syphilitic  tumour. — The  most  impor- 
tant diagnostic  indication  of  the  syphilitic  intracranial  tumour  is 
the  presence  of  definite  manifestations  of  syphilis  in  some  other 
organ  or  tissue,  such,  for  example,  as  intracranial  or  tibial  nodes. 
Buzzard  lays  great  stress  upon  the  presence  of  a  muddy  com- 
plexion and  other  signs  of  a  cachexia,  not  traceable  to  any  visceral 
disease. 

In  those  cases,  in  which  there  is  no  distinct  evidence  of  associated 
syphilitic  lesions,  a  clear  history  of  syphilitic  infection,  and  more 
especially  of  secondary  symptoms,  a  cicatrix  on  the  penis,  or  the 
remains  of  other  syphilitic  lesions,  and  the  fact  that  there  are  no 
definite  (positive)  indications  of  any  other  form  of  new  growth, 
are  important. 

In  this  connection,  I  must  repeat  that  in  many  cases  of  cerebral 
syphilis  the  secondary  symptoms  are  very  slight,  or  sometimes  alto- 
gether absent ;  certainly,  in  some  cases,  they  pass  unobserved  by  the 
patient.  The  fact  that  in  women  the  primary  sore  may  also  pass 
unnoticed,  or  its  significance  may  not  be  realised,  and  the  circum- 
stance that  the  denial  of  syphilis  cannot  always  be  relied  upon,  must 
also  be  remembered. 

The  facts  that  the  patient  is  a  male,  between  the  ages  of  twenty- 
five  and  fifty ;  that  the  headache  is  worse  at   night ;  that  there  is 

''■  Ziemssen's  Cyclopedia  of  Medicine,  vol.  xii.,  p.  303. 


222  PATHOLOGICAL  DIAGNOSIS. 

tenderness  on  skull  percussion ;  the  'presence  of  well-marked  Jack- 
sonian  epilepsy  (indicative  of  a  cortical  and  irritative  lesion) ;  the 
presence  of  localised  paralysis  due  to  a  lesion  of  an  intracranial  nerve 
(more  especially  paralysis  of  the  muscles  supplied  by  the  third  nerve)  ; 
the  occurrence  of  pseudo-apoplectic  seizures  or  prolonged  somnolent 
attacks ;  the  fact  that  the  arrangement  of  the  symptoms  is  anomalous ; 
the  presence  of  many  different  symptoms  which  it  is  impossible  to 
refer  to  a  single  cerebral  lesion ;  and  the  marked  relief  which  in  many 
cases  immediately  follows  vigorous  anti-syphilitic  treatment,  are  other 
points  of  great  diagnostic  importance.  It  is  necessary  to  remember 
that  the  secondari/  effects  of  syphilitic  brain  lesions — such,  for  example, 
as  softenings  due  to  syphilitic  disease  of  a  large  vessel — cannot  be 
cured  by  anti-syphilitic  remedies.     On  this  point  see  page  22-4. 

Glio.mata. 

After  the  scrofulous  and  syphilitic  varieties,  this  is  probably  the 
most  frequent  form  of  brain  tumour.  It  may  occur  in  any  part  of 
the  intracranial  nerve  centres  (cerebrum,  cerebellum,  pons  Varolii,  or 
medulla  oblongata),  and  usually,  I  believe,  has  its  starting-point  in 
the  white  rather  than  in  the  gi'ey  matter  (see  Fig.  87).  Gliomatous 
tumours  are  very  variable  in  size,  but  it  is  common  to  find  large 
portions  of  the  brain  tissue  infiltrated.  Cases  have  come  under  my 
own  observation  in  which  considerably  more  than  half  of  one 
cerebral  hemisphere  has  been  affected  in  this  manner.  This  tendency 
to  infiltrate  the  nervous  structures  is  the  most  characteristic  feature 
of  the  gliomatous  tumour.  The  tumour  tissue  is  never  limited  by  a 
capsule,  and  it  is  impossible  in  many  cases  to  say,  mthout 
microscopical  examination,  where  the  tumour  tissue  ceases  and  the 
normal  brain  tissue  begins. 

The  affected  part  of  the  brain  often  appears  to  be  swollen,  and  is 
usually  of  a  delicate  pink,  or  purplish  pink  colour.  In  other  cases 
the  normal  colour  of  the  affected  part  is  retained  ;  in  others  again, 
nodules  of  firm,  old,  yellow  and  caseous-looking,  or  recent,  black  blood- 
clot  are  scattered  throughout  the  affected  tissue.  The  corpus 
callosum  or  basal  ganglia  may,  in  consequence  of  this  gliomatous 
infiltration,  be  swollen  to   twice  or  three  times   their   usual    size. 


GLIOMATOUS  TUMOURS. 

A 


223 


Fig.  87. — Camera  lucida  dra^vlng  of  a  microscopical  section  tiirough  the  cortex  of 
the  brain  in  a  case  of  glioma.  Stained  with  picro-carmine,  cleared  with  oil  of  cloves, 
and  mounted  in  xylol  balsam  ;  magnified,  Hartnack,  oc.  2,  obj.  1,  tube  in,  and  drawing 
reduced  from  9f  to  5|  inches. 

The  gliomatous  tissue  is  situated  in  the  white  matter,  and  has  not  involved  the 
surface  of  the  brain  cortex. 

The  letter  ^4  points  to  the  pia  mater,  which  is  healthy;  B,  to  the  superficial  part  of  the 
convolution  (grey  matter),  which  is  also  health}'  ;  C,  to  a  dilated  blood-vessel  in  a  portion 
of  the  grey  matter  adjacent  to  the  gliomatous  tissue;  D,  to  a  vessel  passing  into  the  grey 
matter  from  the  surface  of  the  brain  ;  E,  to  the  superficial  part  of  the  tumour,  which  is 
invading  the  deep  layers  of  the  grey  matter  ;  F,  to  vessels  in  the  midst  of  the  tmnour — 
some  of  them  are  small,  others  large  and  varicose  ;  G^,  to  a  cavity  in  the  centre  of  the 
section  (probably  artificial,  and  produced  in  preparing  and  mounting  it)  ;  H,  to  the  glio- 


224 


PATHOLOGICAL  DIAGNOSIS. 


^i^i&^v^^m 


v>^ 


■''}''^f,Ki"' 


t 


When  large  extravasations  of  blood  have  occurred  just  before  death, 
the  condition  is  easily  mistaken  for  an  ordinary  hfemorrhagic 
apoplexy.  A  previous  history  of  headache  and  vomiting,  and  above 
all,  the  presence  of  double  optic  neuritis — a  condition  wliich  seldom, 
if  ever,  occurs  in  ordinary  cerebral  htemorrhage — should  lead  the 
observer  to  suspect  the  true  nature  of  the  condition.  Cysts,  which 
are  sometimes  of  large  size,  may  be  developed  in  connection  with 
gliomatous  tumours. 

In  some  cases,  the  tissue  of 

the   tumour   feels   much  firmer 

than  in  others,  and  two  varieties 

''       of  glioma — the  hard  and  soft — 

have  been  described. 

Ou  microscopical  examina- 
tion, the  tumour  is  found  to  be 
composed  of  small  round  or  oval 
cells,  and  of  extremely  delicate 
fibres  (glial  threads) ;  the  exact 
appearance  which  the  micro- 
scopical section  presents,  depends 
upon  the  method  of  preparation, 
the  ramifying  thread-like  pro- 
cesses, which  project  in  all  direc- 
tions from  the  cellular  elements, 
being  best  displayed  by  the 
"  half-clearing  "  method  of  pre- 
paration. ^ — (See  Figs.  88  and  89.) 
Blood  corpuscles  are  often 
infiltrated  around  the  tissues  of 
the  tumour.  In  several  instances, 
I  have  found  in  the  substance  of 
the  tumour  large  round  ceUular 
elements,  some  of  which  were 
distended  with  clear  fluid  contents,  others  of  which  contained  red  blood 


Jr^ 


mm 


ti^ 


a 


0 


'/;.: 


'^'xim 


B 


Fig.  88. — A  and  B,  camera  lucida  drawings 
ni  portions  of  a  microscopical  section  of  a 
gliomatous  tumour  of  the  brain.  Stained 
with  picro-carmine,  and  mounted  in  Fairant's 
solution.  Both  the  glial  cells  and  glial  fibres 
are  •well  seen. 


^  The  reader  who  is  interested  m  these  histological  details  vnU.  find  a  full  description 
of  this  method  of  preparing  nerve  tissues  in  the  Edinhunjh  Medical  Journal  for  October 
1886,  p.  322. 


GLIOMATOUS  TUMOURS. 


225 


corpuscles  in  their  interior  (see  Fig.  90).     In  many  cases  sarcomatous 
elements  are  to  be  found  in  some  parts  of  the  tumour,  and  in  some 


Fig.  89. — Section  through  a  portion  of  a  gliomatous  tumour,  showing  a 
varicose  and  aneurismally  dilated  vessel  surrounded  with  glial  cells  (half- 
cleared). 


Fig.  90. — Camera  lucida  drawing  of  a  microscopical  section  of  a  portion 
of  a  gliomatous  tumour,  showing  large  round  transparent  cells,  some  of 
which  contain  a  single  nucleus,  others  red  blood  globules.  These  cells  lay 
in  the  midst  of  extravasated  red  blood  corpuscles,  which  have  been  omitted 
from  the  drawing. 

Stained  with  picro-carmine,  half-cleared  with  methylated  spirit  and  oil 
of  cloves,  and  mounted  in  xylol  balsam.    (Magnified — Hartnack,  oc.  3,  obj.  8. ) 

A,  large  cell  containing  a  single  nucleus  ;  B,  B,  cells  containing  red 
blood  corpuscles  ;  C,  red  blood  globules. 

they  are   so  numerous  that  the  tumour  is  rightly  termed  a  glio- 

sarcoma  or  a  sarco-glioma.     Hyaline  degeneration  of  the  vessels  and 

p 


226 


PATHOLOGICAL  DIAGNOSIS. 


myxomatous  degeneration  of  the  tissues  of  the  tumour  are  not  un- 
common.— (See  Figs.  91-94.) 


'^^^^/^' 


Fig.  91. — Camera  lucida  drawing  of  a  portion  of  a  section  of  a  sarcoma- 
tous tumour  of  the  brain,  which  has  undergone  myxomatous  degeneration. 
Stained  with  picro-carmine,  and  mounted  in  Farrant's  solution  ;  magnified, 
Hartnack,  oc.  3,  obj.  8,  tube  out,  and  drawing  reduced  from  6  to  4 
inches. 

In  the  centre  of  the  figure  three  blood-vessels,  one  of  which  [B)  is  empty, 
are  surrounded  by  a  dense  mass  of  small  cells.  The  adjacent  portion  of  the 
section  is  composed  of  large  irregular  and  spindle-shaped  cells  embedded  in 
a  clear  gelatinous  fluid,  which  cannot,  of  course,  be  shown  in  the  illustration. 
The  letter  A  points  to  a  space  filled  with  this  fluid,  and  in  which  ho 
cells  are  seen. 

One  of  the  most  important  structural  characters  of  gliomatous 
tumours,  from  a  clinical  point  of  view,  is  the  enormous  vascularity 
which  they  in  many  instances  present.  In  places  the  tumour  tissue 
may  appear  to  be  composed  entirely  of  large  thin-walled  vessels, 
in  the  interstices   between  which  a  few  glial   cells    are   scattered. 


GLIOMATOUS  TUMOURS. 


227 


Aneurismal  and  varicose  dilatations  of  the  vessels  may  often  be  noticed 
in  such  cases. — (See  Figs.  41  and  42,  pages  118  and  119.) 


Fig.  92. — Camera  lucida  drawing  of  large  branching  and  ribbon-shaped 
cells  from  a  section  of  a  sarcomatous  tumour  of  the  brain,  which  had  under- 
gone myxomatous  degeneration.  Stained  with  picro-carmine,  mounted  in 
Farrant's  solution  ;  and  magnified,  Hartnack,  oc.  3,  obj.  9  immersion,  tube 
out,  and  drawing  reduced  from  4  to  3f  inches. 

The  cells,  some  of  which  contain  several  nuclei,  are  embedded  in  a  clear 
gelatinous  fluid,  in  which  the  transversely  divided  fibres  of  cell  processes  are 
seen  as  fine  dots. 

In  some  cases  of  glioma.  Osier  found  large  cells  and  fibres,  which 
he  describes  as  follow  : — "  (1.)  The  '  spinnen'  or  spider  cells  (charac- 
teristic of  glioma),  which  present  variations  in  size  :  (2.)  Large  spindle- 
shaped  cells,  with  single  large  nuclei  (some  of  the  largest  cells  met 
with  in  tumours) :  (3.)  Cells  like  the  ganglion  cells  of  nerve  centres, 
with  large  nuclei  and  one  or  more  processes ;  they  are  larger  than  the 
spider  cells :  (4.)  Translucent  band-like  fibres,  tapering  at  each  end, 
without  nucleus  or  granular  protoplasm,  regarded  as  vitreous  or 
hyaline  transformation  of  the  large  spindle  cells."  I  have  in  two  or 
three  cases  met  with  cells  and  fibres  resembling  those  described  by 


228 


PATHOLOGICAL  DIAGNOSIS. 


Osier  in  sarcomata  or  glio-sarcomata,  which  had  undergone  the  myxo- 
matous form  of  degeneration  (see  Figs.  91  and  92). 


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GLIOMA  TO  us  TUMOURS. 


229 


"Klebs  (quoted  by  Osier)  holds  that  the  ganglion-like  cells  are 
derived  from  the  nerve  cells  of  the  grey  matter,  and  that  in  the 
development  of  this  variety  of  glioma  all  elements  of  the  nerve  tissue 
participate.  Osier  examined  the  advancing  region  of  the  tumour,  and 
was  not  able  to  satisfy  himself  that  the  nerve  cells  were  in  process 
of  proliferation.  He  thinks  the  large  cells  are  connective  tissue 
elements."  ^     With  this  opinion  my  own  observations  entirely  agree. 

B 


Fig.  94.  —  Glio-sarcomatous  tumour  ;  hyaloid  degeneration  of  vessels. 

The  letter  A  points  to  a  vessel  of  some  size  (filled  with  blood  corpuscles), 
the  walls  of  which  are  partly  infiltrated  with  hyaloid  material  {B),  which  is 
continuous  at  D  (broken  in  mounting),  with  hyaloid  lumps  in  the  surround- 
ing tissue  of  the  tumour,  the  structure  of  which  has,  for  the  sake  of  clearness, 
been  omitted  from  the  drawing.  The  letters  C  0  point  to  small  blood- 
vessels, the  walls  of  which  are  enormously  thickened  and  infiltrated  with  the 
hyaloid  material. 

For  a  more  detailed  account  of  the  histological  characters  of  this  very 
interesting  case,  see  the  Edinburgh  Medical  Journcd,  February  1887,  p.  689. 

Numerous  small  scattered  masses  of  myeline,  which  are  evidently 
derived  from  broken-down  nerve  tubes,  may  in  some  instances  be 
seen  in  the  midst  of  (and  more  especially  at  the  border  of)  the  glio- 
matous  tissue.  In  some  cases  the  microscopical  characters  of  the 
affected  tissue  so  closely  resemble  those  of  chronic  cerebritis,  that 
the  possibility  of  the  tumour  being  due  to  some  toxic  irritant,  possibly 
a  micrococcus,  has  forcibly  suggested  itself  to  me. 

In  some  instances,  the  tumour  extends  by  direct  contact  to  adjacent 

^  FeT^pevs  System  of  Medicine :  Article  on  "Tumours  of  the  Brain,  and  its  Euve- 
lopes,"  by  Drs.  Charles  K.  Mills  and  James  Hendrie,  p.  1047. 


230  PATHOLOGICAL  DIAGNOSIS. 

portions  of  the  opposite  cerebral  hemisphere,  with  which  it  comes  in 
contact ;  in  other  words,  some  ghomata  are  auto-inoculable  (see 
Fig.  47,  page  152). 

The,  sjjccial  diagnostic  features  of  the  gliomatous  tumour. — Gliomata 
may  occur  at  any  age,  but  are,  I  think,  more  common  in  children 
and  young  adults  than  in  old  people.  In  some  instances  the  exciting 
cause  appears  to  be  a  head  injury.  The  rapidity  of  growth  varies 
very  remarkably  in  different  cases.  I  have  seen  a  large  portion  of  the 
brain  tissue  infiltrated,  in  cases  in  which  the  symptoms  were  of  recent 
origin ;  in  other  cases  which  have  come  under  my  notice,  the  glioma 
had  evidently  been  present  for  several  years.  ^ 

In  some  cases,  there  is  very  great,  and  in  others  little  or  no 
increase  of  the  intracranial  pressure,  and  apparently  very  little 
cerebral  irritation.  The  tumour  may  consequently  in  some  cases  be 
almost  entirely  latent ;  while,  in  others,  the  general  symptoms  (head- 
ache; vomiting,  double  optic  neuritis,  &c.)  are  very  prominent. 

Irritative  phenomena,  such  as  attacks  of  Jacksonian  epilepsy,  are 
not  so  common  as  in  some  other  forms  of  tumours  {e.g.,  syphilomata) ; 
in  consequence,  I  beheve,  of  the  fact  that  the  new  growth  usually 
commences  in  the  white  substance,  and  destroys  the  nerve  tubes 
before  it  produces  irritation  of  the  grey  matter.  Ziegler  seems  to 
differ  from  this  opinion,  for  he  states  that  gliomata  are  usually  found 
close  beneath  the  pia  mater.- 

A  gradual  and  progressive  paralysis  without  spasms  is  highly 
suggestive  of  a  subcortical  tumour,  which  is  in  many  cases  a  glioma. 

The  general  nutrition  is,  in  many  cases  of  glioma,  well  preserved. 
Pseudo-apoplectic  attacks,  and  more  especially  repeated  slight  apo- 
plectic seizures  followed  by  paralysis  (i.e.,  apoplectic  attacks  evidently 
the  result  of  hcemorrhagic  extravasations,  rather  than  of  mere  conges- 
tion), are  very  suggestive  of  this  form  of  new  growth. 

In  one  instance  which  I  have  reported,  imperfect  hemiplegia,  wliich 
varied  in  a  remarkable  manner  from  time  to  time,  was  evidently  due 
to  the  pressure  of  a  cyst  (developed  in  connection  with  a  glioma)  upon 
the  motor  fibres  of  the  pjTamidal  tract.  ^ 

^  See  cases  reported  in  the  Edlnhurgh  Medical  Journal  for  January  1887,  pp.  591 
and  623. 

*  Special  Pathological  Anatomy,  section  xii..  p.  314. 

^  See  cases  reported  in  the  Edinburgh  Medical  Journal  for  Januvry  13S7)  P-  623. 


SARCOMATOUS  TUMOURS. 


231 


Saecomata. 

All  the  different  forms  of  sarcoma  may  occur  within  the  skull.  In 
some  cases  the  new  growth  is  primary,  and  has  its  starting-point  in 
{a)  the  bones  of  the  cranial  wall,  (&)  the  membranes,  or  (c)  the  con- 
nective tissue  of  the  brain  itself  (in  the  form  of  the  glio-sarcomatous 
or  sarco-gliomatous  tumour  already  described).  In  others  the  sarcoma 
is  secondary  to  a  similar  form  of  new  growth  in  some  other  part  of 
the  body,  commonly  in  the  lungs. 


Fig.  95. — Camera  lucida  drawing  of  a  microscopical  section  of  a  cerebral 
tumour,  composed  of  extremely  fine  and  delicate  spindle  cells.  (Magnified 
— Hartnack,  oc.  3,  obj.  7,  and  tube  out. ) 

The  letters  a  a  point  to  masses  ;  and  6  6  to  individual  spindle  cells. 

The  size  of  intracranial  sarcomatous  tumours  is  very  variable,  and 
depends  to  a  large  extent  upon  the  primary  or  secondary  nature  of  the 
condition.  Primary  tumours  may  attain  to  the  size  of  the  fist  or  even 
larger  (see  Eigs.  1-4,  pages  11  to  1-4).  In  some  cases,  the  tumour  is 
limited  by  a  well-defined  capsule  ;  in  others  (sarco-gUomatous  growths 
more  especially),  it  infiltrates  the  nervous  tissues.  The  effects  pro- 
duced upon  the  nervous  structures  are  very  different  in  different  cases. 


232 


PA  THOL O GICAL  DIA  GNOSIS. 


Slow  growing,  encapsuled  sarcomata  produce  atrophy  rather  than 
irritation  of  the  brain  tissue  with  which  they  come  into  contact ;  in 
such  cases,  the  general  symptoms  may  be  very  severe,  but  the  localising 
indications  slight  or  altogether  absent. 

Eapidly  growing  sarcomata,  which  infiltrate  the  brain  tissue,  may 
produce  marked  irritative  phenomena.  In  the  remarkable  case  repre- 
sented in  Figs.  33  and  34,  pages  109  and  110,  the  grey  matter  of  the 
brain  was  so  extensively  involved,  that  "  diffuse  "  cerebral  symptoms 
were  produced. 


Fig.  96. — Cells  from  a  myeloid  sarcoma  of  the  brain.  (Magnified — 
Hartnack,  oc.  3,  obj.  8,  tube  out,  and  drawing  reduced  from  4  to  3j 
inches. ) 

The  microscopical  characters  vary  very  greatly  in  different  cases, 
— see  Figs.  33  to  38,  pages  109  to  114,  and  Figs.  95  to  106,  in  which 
the  structure  of  some  of  the  more  interesting  varieties,  which  have 
come  under  my  own  notice,  is  shown. 


SARCOMATOUS  TUMOURS. 


233 


Some  forms  of  sarcoma  (more  especially  sarco-gliomatoiis  tumours) 
are  remarkably  vascular.  HcEmorrhagic  extravasations  may  occur  in 
such  cases,  as  in  ordinary  diomata. 


Fig.  97. — Transverse  vertical  section 
through  the  frontal  lobes  in  a  case  of 
melanotic  sarcoma,  showing  several  de- 
posits {A,  B,  C,  D)  of  some  size.  (Re- 
duced from  a  photograph.) 


Fig.  98. — Transverse  vertical  section 
through  the  brain  of  S.  E.  M.  at  the  level 
of  the  anterior  end  of  the  corpus  callosum, 
showing  three  small  melanotic  masses  (E, 
F,  G).     (Reduced  from  a  photograph.) 


The  dia/jnostic  features  of  sarcomata. — There  are  practically  no 
special  indications  in  the  great  majority  of  cases,  unless  the  brain 
tumour  be  secondary  to  some  well-marked  sarcomatous  lesion  elsewhere. 


Fig.  99. — Transverse  vertical  section  through  the  brain  of  S.  E.  M.  at 
the  level  of  the  optic  chiasma,  shelving  numerous  melanotic  deposits,  the 
majority  of  which  are  of  small  size.     (Reduced  from  a  photograph.) 

The  letter  H  points  to  a  small  nodule  in  the  left  island  of  Reil ;  /,  to  a 
large  superficial  mass  in  the  anterior  longitudinal  fissure  ;  K,  to  a  small  mass 
in  the  right  lenticular  nucleus  ;  Z,  to  a  nodule  in  the  white  matter  of  the 
right  temporo-sphenoidal  lobe.  Many  smaller  nodules  ( which  are  unlettered) 
are  seen  in  both  hemispheres.  In  this  section  the  nodules  on  the  two  sides 
of  the  brain  are  remarkably  symmetrical  in  distribution. 

Should  symptoms,  indicative  of  a  tumour  growing  inwards  from 
the  bones  or  membranes,  occur  in  a  young  person  in  whom  there  is 


234 


PA THO LOGICAL  DIA GNOSIS. 


no  suspicion  of  syphilis,  and  no  likelihood  (from  the  history  or 
personal  condition)  of  tubercle,  the  probability  of  the  tumour  being  a 
sarcoma  is  considerable.     The  fact  that  tlie  tumour   had  apparently 


Fig.  100. — Transverse  vertical  section  through  the  brain  of  S.  E.  M. , 
just  behind  the  optic  chiasma,  showing  the  position  of  the  melanotic  nodules. 
(Reduced  from  a  photograph.) 

The  letter  ^1/  points  to  a  large  nodule  at  the  vertex  ;  iV,  to  a  small  com- 
mencing nodule  in  the  white  matter  of  the  centrum  ovale  ;  0,  to  a  small 
nodule  in  the  right  lenticular  nucleus  (there  are  several  small  nodules  in  the 
lenticular  nucleus  and  external  capsule  of  the  left  side)  ;  /*,  to  a  nodule  of 
some  size  invohnng  symmetrical  parts  of  the  optic  thalami. 


Fig.  101. — Transverse  vertical  section  through  the  brain  at  the  level  of 
the  greatest  convexity  of  the  pons  Varolii,  in  a  case  of  melanotic  sarcoma, 
showing  the  position  of  melanotic  nodules  (Q  ii  -S)  in  the  brain,  and  a  large 
nodule  (T)  in  the  pons,  involving  the  right  pyramidal  tract.  (Reduced 
from  a  photograph. ) 

resulted  from  a  head  injury  would,  in  my  opinion,  make  the  diagnosis 
of  sarcoma  still  more  probable.  The  general  state  of  nutrition  is,  in 
many  cases  of  intracranial  sarcoma,  well  preserved. 


CANCEROUS  TUMOURS. 


235 


Caecinomata. 

Both  primary  and  secondary  cancers  of  the  brain  are  compara- 
tively rare.  According  to  Obermeier  primary  cancer  is  the  more 
common.  ^ 

Primary  cerebral  cancer  usually  originates  either  from  the  outer 
or  inner  surface  of  the  dura.  In  the  former  case,  the  new  growth 
may  make  its  way  through  the  bones  of  the  skull  and  produce  an 
external  f ungating  tumour  (such  as  is  represented  in  Figs.  69,  70,  and 
71)  ;  in  the  latter,  the  cancer  progresses  inwards  and  invades  the 


Fig.  102. — Transverse  vertical  section 
through  the  brain  in  a  case  of  melanotic 
sarcoma,  showing  numerous  melanotic  de- 
posits both  in  the  brain  and  cerebellum. 
(Reduced  from  a  photograph.) 

The  letter  TJ  points  to  a  nodule  of  some 
size  in  the  left  lateral  lobe  of  the  cere- 
bellum ;  F,  to  the  left  lateral  ventricle  ;  W 
and  X  to  large  nodules  in  the  right  cerebral 
hemisphere  ;  F  to  a  large  nodule  in  the 
middle  lobe  of  the  cerebellum. 


Fig.  103. — Transverse  vertical  section 
through  the  brain  in  the  case  of  S.  E.  M., 
at  the  level  of  the  lov^er  end  of  the 
medulla  oblongata,  showing  the  position 
of  the  melanotic  nodules.  (Reduced  from 
a  photograph. ) 

The  letters  T^,  F,  point  to  the  lateral 
ventricles  ;  Z  to  a  large  mass  cif  new 
growth  involving  the  middle  lobe  of  the 
cerebellum  ;  Z'  to  a  small  nodule  in  the 
right  lateral  lobe  of  the  cerebellum. 


brain  tissues.  It  would  appear  that  the  dura  is  rarely,  if  ever,  per- 
forated, except  at  the  seat  of  the  openings  which  normally  exist  for 
the  passage  of  blood-vessels  or  nerves. 

Secondary  cancers  usually  occur  in  the  form  of  round  nodules, 
several  of  which  are  often  present  in  the  same  case  (see  Fig.  107,  page 
238,  Fig.  7,  page  32,  and  Fig.  56,  page  171). 

The  microscopical  characters  of  the  new  growth  are  the  same  as 
those  of  cancer  elsewhere.     In  one  instance  I  have  met  with  the  rare 


^  Ziemssen's  Cydopcedia  of  Medlchie,  vol.  xii.,  p.  233. 


236  PATHOLOGICAL  DIAGNOSIS. 

foiTQ  of  new  growth  in  wliicli  the  cells  were  essentially  epithelial  in 
character,  but  the  stroma  made  up  entirely  of  delicate  walled  vessels. 
In  the  case  to  which  I  refer,  and  which  is  represented  in  Figs.  108, 
109,  110,  page  239  d  scq.,  the  tumour  had  originated  on  the  surface 
of  the  brain,  apparently  in  the  soft  membranes ;  it  had  invaded 
and  extensively  infiltrated  the  brain  tissue,  a  large  portion  of  the  left 
hemisphere  being  in  the  condition  of  "  red  softening."  The  term 
alveolar  sarcoma  is  sometimes  applied  to  this  form  of  new  growth. 


«>y^, 


^^^^»|i  •..  •>■■     -.-;  -^, 


IMi 


Fig.  104. — Microscopical  section  through  a  portion  of  the  white  matter 
of  the  brain  in  the  case  of  S.  E.  M.,  showing  a  nodule  of  melanotic  sarcoma 
in  an  early  stage.  Low  power  (Hartnack,  oc.  3,  obj.  4,  and  tube  out ; 
drawing  reduced  from  3f  to  d'^  inches). 

The  sarcomatous  ceUs  are  massed  round  the  blood-vessels  ;  some  of  the 
vessels  in  the  surrounding  portions  of  the  brain  substance  are  very  much 
dilated. 

The  letter  E  points  to  a  mass  of  pigmented  sarcomatous  cells. 

Ziegler  describes  its  characters  as  follows  : — "  There  are  sarcomata 
which  have  a  structure  resembling  that  of  gland  tissue,  or  of  epithelial 
new  growths.  This  appearance  of  structure  is  due  in  part  to  the 
epithelial  look  of  the  cells,  but  chiefly  to  their  aggregated  arrange- 
ment in  groups  separated  by  fibrous  septa.  Such  tumours  are 
described  as  alveolar  sarcomata.  .  .  .  Tumours  of  this  kind  occur 
chiefly  in  the  skin,  but  they  are  also  met  with  in  the  bones,  lymphatic 
glands,  and  pia  mater.  .  .  .  The  way  in  which  the  alveolar 
structure  is  developed  can  often  be  clearly  made  out,  especially  in 


ALVEOLAR  SARCOMATA. 


237 


tumours  of  the  central  nervous  system.  The  normal  intervascular 
tissue  is  transformed  into  masses  of  sarcoma  cells,  while  septa  are 
formed  between  the  cell  masses  by  the  fibrous  tissues  lying  along  the 
course  of  the  vessels.  In  other  cases  it  looks  as  if  a  plexus  of  pre- 
existing or  new  formed  vessels  took  on,  as  it  were,  an  investment  of 


Fig.  105.— Individual  cells  from  sarcomatous  nodules  in  the  case  of  S.  E. 
(Magnified— Hartnack,  oc.  3,  obj.  8,  and  tube  dra%vn  out.) 

The  letter  A  points  to  large  cells  from  a  nodule  in  the  dura  mater  ;  B 
and  C,  to  small  round  cells  from  a  commencing  nodule  in  the  brain  ;  B,  I), 
to  large  cells  filled  with  large  melanotic  granules  from  a  nodule  in  the  tonsil! 


Fig,  106.— Microscopical  section  through  a  nodule  of  melanotic  sarcoma 
attached  to  the  dura  mater  in  the  case  of  S.  E.  M.  (Magnified— Hartnack 
oc.  3,  obj.  8,  and  tube  drawn  out.)  ' 

The  letter  A  points  to  the  deepest  layer  of  the  dura  (a  small  portion  of 
which  is  only  represented,  for  the  membrane  was  very  much  thickened) 
The  dura  is  seen  to  be  infiltrated  with  deeply  stained  leucocytes  and  enlarcred 
connective  tissue  corpuscles.  The  letters  B  B  point  to  septa  of  fibrous  tissue 
(which  are  also  infiltrated  with  leucocytes)  passing  from  the  dura  into  the 
tumour  tissue  ;  C  and  B,  to  large  sarcomatous  cells  containing  several  nuclei. 

cells,  and  this  grew  thicker  and  thicker,  till  at  length  the  inter- 
vascular spaces  were  entirely  filled  up.     Accordingly  we  find  this 


238 


PATHOLOGICAL  DIAGNOSIS. 


form  of  new  growth  described  as  plexiform  angio-sarcoma.  It  has 
also  been  described,  and  not  infrequently,  as  endothelioma.  On  this 
view  the  cell  nests  arise  by  proliferation  from  endothelial  cells. 
This  certainly  happens  when  masses  of  cells  are  formed  from  the 


Fig.  107. — Surface  of  the  frontal  end  of  the  left  hemisphere  of  the  brain 
in  a  case  of  disseminated  cancer,  sho^^•iug  a  nodule  of  new  growth  (.4) 
adherent  on  the  one  side  to  the  dura,  and  on  the  other  to  the  substance  of 
the  brain.  (Copied  from  a  photograph,  and  somewhat  less  than  the  actual 
size  of  the  preparation. ) 

The  letter  F  is  placed  at  the  anterior  end  of  the  frontal  lobe  ;  the  letter 
A ,  which  is  placed  on  the  reflected  dura  mater,  points  to  the  tumour. 

endothelial  covering  of  the  subarachnoid  mesh- work  of  the  pia  mater ; 
the  masses  afterwards  group  themselves  into  "  nests."  Sometimes  the 
proliferous  endothelial  cells  of  the  pia  mater  are  aggregated  into 
small  spherical  nodules  of  a  peculiar  lustrous  appearance.  The 
tumour  into  which  the  membrane  is  transformed  then  contains  small, 
shining,  pearly  bodies,  made  up  of  laminated  layers  of  squamous  or 


PLEXIFORM  ANGIOSARCOMA  :   VASCULAR  CANCER.     239 


■■r. 


Fig.  108. — Camera  lucida  drawing  of  a  section[,through  a  portion  of  the  brain  and  its 
membranes  in  a  case  of  plexiform  angio-sarcoma  (?  vascular  cancer).  Stained  with  picro- 
carmine,  cleared  with  oil  of  cloves,  and  mounted  in  xylol  balsam.  (Magnified — Hartnack, 
oc.  2,  obj.  1,  tube  in,  and  drawing  reduced  from  12  to  Z\  inches.) 

The  letter  A  points  to  the  greatly  thickened  dura  mater,  in  which  numerous  vessels, 
some  of  large  size  (.ff),  are  seen  ;  B,  to  the  thickened  soft  membranes  in  which  the  tumour 
was  embedded,  and  from  which  it  seemed  to  have  originated ;  C,  to  a  portion  of  the  tumour 
which  is  situated  in  the  brain  tissue ;  Z>,  to  the  portion  of  the  section  which  is  more  highly 
magnified  in  Fig.  110  ;  E,  to  the  deeper  portion  of  the  cortex  which  is  in  the  process  of 
being  invaded  by  the  new  growth,  and  is  in  a  condition  of  red  softening  ;  Li,  to  a  portion 
of  the  dura  (not  much  thickened)  which  is  shown  more  highly  magnified  in  Fig.  110  ;  F, 
to  newly  formed  vessels  in  the  superficial  part  of  the  cortex  which  is  invaded  by  the 
tumour ;  K,  K,  K,  to  large  hsemorrhagic  extravasations  in  the  cortex ;  L,  to  the  haemor- 
rhagic  extravasation,  which  is  represented  more  highly  magnified  in  Fig.  110. 


240 


PATHOLOGICAL  DIAGNOSIS. 


tubular  cells.      Such   tumours   have  been  called  cholesteatomata  or 
pearly  tumours."  ^ 

In  Figs.  Ill  and  112,  page  242,  I  have  represented  a  remarkably 
fine  example  of  an  endothelioma,  for  which  I  am  indebted  to  my 
friend  Dr.  T.  W.  M'^Dowall,  who  has  recorded  the  case  in  the  Journal 
of  Mental  Science,  April  1884. 
D 


Fig.  109. — Camera  lucida  drawing  of  a  microscopical  section  of  a  plexi- 
fonri  angio-sarcoma  (?  vascular  cancer)  of  the  brain.  Stained  with  picro- 
carmine,  cleared  with  oil  of  cloves,  and  moimted  in  xylol  balsam.  (Magnified 
— Hartnack.  oc.  3,  obj.  8,  tube  out,  and  drawing  reduced  from  5 J  to  3  inches.) 

The  tumour  is  composed  of  a  network  of  thin-walled  vessels,  in  the 
interstices  of  which  roimd  epithelial-like  cells,  each  containing  a  single  large 
nucleus,  are  densely  packed. 

The  structure  of  tbis  tumour  seems  to  me  essentially  different 
from  the  vascular  cancer  or  alveolar  sarcoma  represented  in  Figs.  108, 
109,  and  110. 

The  diagnostic  indications  suggestive  of  the  cancerous  nature  of  an 
intracranial  tumour  are  in  many  cases  insufl&cient  to  enable  an 
opinion  of  any  value  to  be  arrived  at.  Perforation  of  the  bones  of  the 
skull  and  the  presence  of  an  external  fungating  growth  is,  so  far  as  I 
know,  a  certain  sign  of  cancer  or  sarcoma.  The  fact  that  a  cancerous 
tumour  has  been  previously  removed,  or  the  presence  of  cancer  in 
other  organs,  is  likewise  all-important.  Failing  these,  the  facts  that 
the  patient  is  old,  and  that  he  inherits  a  strong  tendency  to  cancer,  are 

1  Ziegler's  General  Pathology,  p.  220. 


PLEXIFORM  ANGIOSARCOMA. 


241 


Fig.  110. — Camera  lucida  drawing  of  a  microscopical  section  through 
the  membranes  and  cortex  of  the  brain  in  a  case  of  plexiform  angio-sarcoma 
(?  vascular  cancer).  Stained  with  picro-carmine,  cleared  with  oil  of  cloves, 
and  mounted  in  xylol  balsam.  (Magnified — Hartnack,  oc.  3,  obj.  4,  tube 
out,  and  drawing  reduced  from  10  to  5  inches.) 

The  letter  A  points  to  the  thickened  dura  mater  ;  B,  to  the  new  growth, 
which  is  situated  between  the  dura  and  the  surface  of  the  brain  (C). 

The  tumour  is  composed  of  a  network  of  thin-waHed  vessels  well  shown 
in  the  figure,  the  interstices  of  which  are  filled  with  cells  not  represented  in 
the  figure  (in  which  the  solid  tissue  of  the  tumour  has  been  shaded  black  so 
as  to  bring  out  the  vessels). 

The  brain  tissue  was  extensively  invaded  by  the  tumour,  and  there  were 
numerous  hsemorrhagic  extravasations  (two  of  which  are  represented  in  the 
drawing)  in  the  brain  cortex.  The  greater  part  of  the  left  hemisphere  of  the 
brain  (in  which  the  tumour  was  situated)  was  in  a  condition  of  red  softening. 

The  cervical  glands  were  much  enlarged  and  infiltrated  ^\dth  the  same 
form  of  new  growth. 

O 


242 


PA  THOL O GICAL  DIA  GNOSIS. 


suggestive  (though  by  no  means  very  strong  evidence)  that  the  intra- 
cranial tumour  is  cancerous.  The  negative  evidence,  that  there  are 
no  positive  indications  of  any  other  form  of  new  growth  is  also  of 
some  value. 


Fig.  111.— The  left  hemisphere  of  the  brain  in  Dr.  T.  W.  M<:Dowair8 
case  of  endothelioma. 

The  letter  T  points  to  the  tumour,  which  is  situated  at  the  under  surface 
of  the  tip  of  the  frontal  lobe. 


Tig.  112. — Camera  lucida  drawing  of  microscopical  section  of  the  endo- 
thelioma represented  in  Fig.  111.  Stained  with  picro-carmine,  cleared  with 
oil  of  cloves,  and  mounted  in  xylol  balsam.  (Magnified — Hartnack,  oc.  3, 
obj.  8,  and  tube  out. ) 

The  letter  a  points  to  the  endothelial  cells,  seen  as  small  spindles  between 
the  cells'  nests,  c  c  ;  the  letter  b  to  the  edge  of  a  large  mass  of  the  tumour, 
which  is  not  shown  in  the  figure. 


RARE  AND  UNIMPORTANT  FORMS  OF  TUMOURS.     243 

Rare,  and  unimportant  forms  of  Tumour. 

Hyperplasia  of  the  pineal  gland  occasionally  occurs.  No  case  has 
come  under  my  own  observation.  According  to  Obermeier,  it  is 
formed  upon  essentially  the  same  structural  type  as  glioma ;  the 
tumour  may  be  as  large  as  a  walnut,  or  even  larger.  ^ 

The  symptoms  may  be  partly  due  to  pressure  upon  the  corpora 
quadrigemina,  and  partly  to  compression  of  the  veins  of  Galen  and 
resulting  hydrocephalus. 

Psammomata,  which  occur  in  the  form  of  small,  hard,  often  stony 
tumours,  usually  about  the  size  of  a  cherry  stone,  are  of  little  or  no 
clinical  interest,  for  they  very  rarely  give  rise  to  symptoms.  They 
spring  from  the  membranes  of  the  brain,  are  usually  situated  at  the 
base,  and  on  microscopical  examination  are  found  to  contain  sand- 
like particles  identical  with  those  which  are  normally  found  in  the 
pineal  gland. 

Simple  fibrous,  osseous,  and  fatty  tumours  are  occasionally,  but 
very  rarely,  met  with  within  the  cranial  cavity. 

Melanoma  is  a  rare  pigmented  tumour,  which,  according  to  Virchow, 
has  its  origin  in  the  pigment  cells  of  the  dura  mater.  It  is  usually  of 
small  size,  is  sometimes  multiple,  but  does  not  seem  to  be  attended 
with  any  symptoms. 

Neuroma  is  the  term  given  to  a  genuine  hyperplasia  of  the  grey 
substance,  which,  according  to  Obermeier's  description,  "  may  be  found 
in  the  shape  of  small  tumours,  varying  in  size  from  that  of  a  millet- 
seed  to  that  of  a  pea,  and  situated  on  the  ventricular  surface,  in  the 
white  substance,  or  on  the  outer  surface  of  the  brain."  No  tumour 
of  this  description  has  come  under  my  notice.  The  condition  has 
been  very  rarely  observed,  and  only  in  persons  with  some  mental 
aberration,  congenital  or  acquired.  As  Obermeier  suggests,  it  may 
well  be  doubted  whether  the  neuromatous  tumours  were  in  such  cases 
the  cause  of  the  mental  condition.  Be  this,  however,  as  it  may,  when 
viewed  as  a  cerebral  tumour,  the  neuroma  is  a  condition  of  no 
clinical  importance. 

The  different  forms  of  cyst  have  been  previously  alluded  to,  and 
need  not  be  described. 

*  Ziemssen's  Cyclopcedia,  vol.  xii.,  p.  234. 


CHAPTER   X. 

PEOGXOSIS— DUEATIOX,  COUESE,  AXD  TEEMIXATIOX— 
TEEATMEXT. 

The  prognosis  in  all  cases  of  intracranial  tumour  is  most  uncertain, 
inasmuch  as  there  is  always  a  liability  to  sudden  death.  But  barring 
4;his  accident,  which  cannot  be  foreseen,  it  may  be  stated  as  a  general 
rule  that  the  progress  of  the  great  majority  of  cases  is  steadily  down- 
wards, with  perhaps  periods  of  remission  or  improvement.  The 
prognosis  is  therefore  as  a  rule  most  unfavourable.  In  confirmation 
of  this  statement,  I  may  add  that  the  remains  of  old  cured  tumours — 
other  than  the  remains  of  former  syphilitic  lesions — are  very  rarely 
indeed  found  post  mortem.  I  have  myself  only  come  across  one 
case  of  this  kind  in  at  least  a  thousand  autopsies.  A  microscopical 
section  of  this  specimen — a  small,  hard  tumour  in  the  cerebellum, 
about  the  size  of  a  threepenny  piece — is  represented  in  Fig.  113. 

In  syphilitic  cases,  remarkable  improvement  often  results  from  a 
vigorous  anti-syphilitic  plan  of  treatment,  and  in  some  cases  a  com- 
plete cure  seems  to  be  eftected;  and  in  tubercular  cases  arrested 
development  of  the  new  growth,  but  very  rarely  complete  cure, 
occasionally  occurs.  But  even  in  the  most  favourable  cases,  the 
syphilitic  lesion  is  liable  (as  the  result,  perhaps,  of  an  injury  to  the 
head,  or  other  exciting  cause)  to  take  on  renewed  activity,  and  a 
relapse  to  occur. 

It  is  important,  too,  to  realise  and  emphasise  the  fact  that  in  cases 
of  syphilitic  nerve  lesion  the  symptoms  for  the  most  part  depend 
upon  the  secondary  alterations  (softenings,  destructions,  &c.)  wliich  the 
lesion  produces  in  the  nervous  structures ;  and  that,  although  anti- 
syphilitic  treatment  may  be  able  to  remove  the  primary  (syphihtic) 
lesion,  it  is  quite  powerless  to  restore  or  renew  the  nerve  tissue  which 


PROGNOSIS. 


245 


has  been  damaged  or  destroyed  by  that  lesion.  Hence  in  syphilitic 
cases,  although  the  prognosis  as  regards  life  should  never  perhaps  be 
hopeless,  however  desperate  the  condition  may  appear,  the  opinion  as 
regards  complete  recovery,  removal  of  paralysis,  &c.,  depends  upon 


Fig.  113. — Camera  lucida  drawing  of  a  microscopical  section  through  a 
portion  of  the  cerebellum,  showing  an  old  cured  tumour,  surrounded  by  a 
dense  mass  of  fibrous  tissue.  (Magnified— Hartnack,  oc.  3,  obj.  1 ;  tube  in  • 
drawing  reduced  from  5|  to  4  inches. )  '  ' 

_  The  letter  E  points  to  the  tumour,  which  contained  the  remains  of  large 
epithelial-like  cells,  and  which  was  densely  infiltrated  with  calcareous  par- 
ticles ;  F,  to  the  thick  fibrous  tissue  surrounding  the  tumour  ;  .1,  to  the  white 
matter  of  the  cerebellum  ;  B,  to  the  normal  grey  matter  of  the  cerebellum  ; 
C  C,  to  atrophied  portions  of  the  cerebellar  cortex  ;  D,  to  &  cavity,  which  is 
partly  artificial  (due  to  a  portion  of  the  normal  cerebellar  tissue  having  fallen 
out  of  it  during  the  act  of  preparation),  but  which  was  partly  fillell  with 
dense  fibrous  tissue. 

In  the  atrophied  portions  of  the  cerebellum  ( C  C)  the  normal  nerve  tissue 
has  been  entirely  destroyed. 

the  amount  and  kind  of  damage  to  the  nervous  structiu'e  proper,  as 
well  as  upon  the  period  of  the  disease  at  which  the  treatment  is 


246  PROGNOSIS,   COURSE,  AND  TERMINATION. 

commenced.  In  a  case  of  hemiplegia,  due  to  extensive  softening 
of  the  centrum  ovale,  the  result  of  syphilitic  disease  of  the  cerebral 
vessels,  the  prognosis  as  regards  the  removal  of  the  paralysis  is  little, 
if  at  all,  better  than  in  a  case  of  hemiplegia  due  to  haemorrhagic 
extravasation  or  embolic  blocking.  For  even  if  the  syphilitic  arterial 
disease  could  be  removed  by  anti-syphilitic  remedies,  the  nervous 
elements  which  have  been  softened  and  destroyed  cannot  be  restored 
to  their  former  condition.  Again,  it  must  be  remembered  that  the 
cicatrix,  which  is  left  behind  a  cured  syphilitic  gumma,  may  be  the 
source  of  a  long-continued  or  permanent  epilepsy. 

When,  however,  the  alteration  in  the  nervous  elements  falls  short 
of  complete  destruction — when,  for  instance,  there  is  simply  impaired 
nutrition  as  the  result  of  deficient  (and  not  completely  arrested)  blood 
supply — most  marked  improvement  may  result  from  anti-syphilitic 
remedies,  the  removal  of  the  endarteritis  or  the  periarteritis  allowing 
of  a  freer  blood  supply  to  the  nervous  elements.  Syphilitic  disease  of 
the  larger  vessels  is  said  to  resist  anti-syphilitic  remedies.  Be  that 
as  it  may,  I  am  quite  satisfied  that  the  syphilitic  lesions  of  the  smaller 
vessels  may  be  removed  by  anti-syphilitic  treatment. 

Again,  in  those  cases  in  which  the  symptoms  depend  upon  irrita- 
tion rather  than  upon  destruction  of  the  nervous  tissue  (and  in  which 
enlargement  of  the  connective  tissue  corpuscles,  and  infiltration  of  the 
nervous  structures,  in  the  immediate  neighbourhood  of  the  gumma, 
with  nuclear  elements,  are  the  most  striking  histological  changes), 
the  most  striking  and  brilliant  results  may  often  be  obtained  by  a 
vigorous  anti- syphilitic  treatment. 

In  those  cases,  too,  in  which  the  peripheral  nerve  trunks  (such  as 
the  trunk  of  the  third  nerve)  are  extensively  affected  by  syphihtic 
infiltration,  most  remarkable  restoration — removal  of  paralysis,  and 
recovery  of  motor  power — is  in  many  cases  effected. 

In  watching  the  effects  of  treatment  in  syphilitic  as  well  as  in 
other  forms  of  tumour,  it  is  important  to  remember  that  remarkable 
remissions  and  periods  of  apparent  recovery  not  infrequently  occur. 
In  the  remarkable  case  of  sarcoma  shown  in  Figs.  2,  3,  4,  pages  12, 
13,  and  14,  the  improvement  under  treatment  was  most  striking ;  the 
patient  expressed  herself  as  feeling  quite  well,  and  had  indeed  made 
arrangements  to  leave  the  hospital  the  very  morning  following  the 
sudden  epileptiform  seizure  which  proved  fatal. 


CAUSES  OF  DEATH.         ■  247 

In  addition  to  the  pathological  character  of  the  new  growth,  the 
possibility  of  its  being  removed  by  surgical  interference  is  perhaps 
the  most  important  element  in  forming  the  prognosis,  but  this  point 
will  be  more  appropriately  considered  under  the  head  of  treatment. 

The  causes  of  death  are  various.  In  some  cases,  the  patient  dies 
suddenly  in  an  epileptic  or  apoplectic  fit,  or  in  one  of  the  pseudo- 
apoplectic  attacks  which  do  not  depend  upon  hsemorrhagic  extrava- 
sation. Tumours  in  the  neighbourhood  of  the  medulla  oblongata  may 
probably  cause  sudden  death  by  suddenly  arresting  the  respiration 
or  the  heart. 

Dr.  Hughlings  Jackson  states  that  sudden  deaths  may  be  due  to 
the  violence  of  the  pain  and  suffering.  He  states,  "  this  has  happened 
in  a  case  of  cerebellar  abscess  from  ear  disease,-^the  abscess  had  not 
ruptured."  And  again,  "intense  persisting  pain,  in  cases  of  optic 
neuritis,  makes  one  fear  that  the  patient  may  die  suddenly."  ^  That  is 
what  we  might,  a  priori,  expect,  for  there  is  every  reason  to  suppose 
that  sudden  arrest  of  the  action  of  the  heart  may  be  produced  by 
intense  pain,  fear,  &c. ;  and  in  some  cases  of  intracranial  tumour  the 
headache  is  most  intense,  and  occurs  in  sudden  paroxysms. 

In  other  cases  of  intracranial  tumour,  death  is  gradual,  either  as 
the  result  of  exhaustion,  long-continued  suffering,  the  pressure  of  the 
tumour  upon  important  parts,  such  as  the  pons  Varolii  or  medulla 
oblongata,  the  gradual  deterioration  of  the  mental  faculties  and  bodily 
functions  which  accompanies  copious  ventricular  dropsy,  or  in  con- 
sequence of  the  presence  of  associated  lesions  in  the  great  viscera  of  the 
thorax  or  abdomen  (tubercle  in  the  lungs  or  intestine,  cancer  in  the 
stomach  or  liver,  for  example).  Eespiratory  complications  (bronchitis, 
oedema  of  the  lungs,  &c.),  bedsores,  or  cystitis  are  in  many  cases  the 
immediate  cause  of  death. 

Treatment. 

The  drug  treatment  of  intracranial  tumours  is,  speaking  generally, 
most  unsatisfactory.  Syphilitic  tumours  may,  in  most  cases,  be  mate- 
rially benefited,  and  in  some  completely  cured,  by  anti-syphilitic 
remedies — iodide  of  potassium  and  mercurials.     The  iodide  must  be 

^  Transactions  of  the  Ophthalmolojical  Society  of  the  United  Kingdom,  vol.  i.,  p.  75. 


248  TREATMENT. 

given  in  large  doses,  at  least  thirty  grains  three  times  daily,  I  have 
again  and  again  seen  most  striking  results  obtained  by  these  large 
doses,  when  smaller  quantities  (five  or  ten  grains)  have  been  previously 
given  with  little  or  no  benefit.  The  administration  of  five-grain 
doses  of  iodide  of  potassium  in  cerebral  syphilis  is,  in  most  instances, 
useless.  If  thirty  grains  three  times  daily  is  not  followed  by  marked 
improvement,  I  am  in  the  habit  of  increasing  the  dose  to  thirty  grains 
four,  five,  or  six  times  a  day ;  and  if  the  iodide  alone  does  not  relieve, 
I  prescribe,  in  addition,  mercurials  (either  in  the  form  of  corrosive 
sublimate  internally,  or  as  mercurial  inunction  externally).  I  agree 
with  Buzzard  in  thinking  that,  in  some  cases  in  which  there  is  no  im- 
X)rovement  under  the  iodide  alone,  the  addition  of  mercurials  is 
followed  by  marked  benefit. 

In  syphilitic  cases  I  am  in  the  habit  of  continuing  the  iodide  for 
week-s  or  months  ;  and  I  have  never  seen  any  injurious  effects  from 
large  doses  given  in  this  way.  In  one  of  my  cases,  the  patient  took 
thirty  grains  three  times  daily  for  at  least  twenty  months  without  the 
slightest  appearance  of  any  bad  effect. 

Wood  speaks  highly  of  sarsaparilla,  given  in  the  form  of  a  mixture 
of  equal  parts  of  the  compound  fluid  extract  and  the  compound  syrup 
of  sarsaparilla  of  the  American  Pharmacopoeia.  He  states  that  the 
compound  syrup  of  sarsaparilla  covers  the  disagreeable  taste  of  the 
iodide  of  potassium  better  than  any  other  vehicle  with  which  he  is 
acquainted.  ^ 

In  some  tubercular  cases,  the  iodide  of  potassium  seems  beneficial ; 
in  such  cases  I  usually  give  it  in  smaller  doses  than  in  cases  of  syphilis 
(five-grain  doses  for  an  adult  three  times  daily),  together  with  cod 
liver  oil,  and  other  general  remedies  which  are  usefid.  in  phthisis. 

Possibly  the  inunction  of  iodoform  ointment  into  the  scalp,  which 
is  said  to  have  been  followed  by  a  cure  in  some  cases  of  tubercular 
meningitis,  or  the  internal  administration  of  iodoform  in  the  form  of 
pills,  may  prove  beneficial  in  some  tubercular  brain  tumours. 

In  some  cases  of  sarcoma,  arsenic  seems  to  restrain  the  develop- 
ment of  the  new  growth.  I  cannot,  however,  say  that  I  have  ever 
seen  any  distinct  relief  from  the  administration  of  this  remedy  in 
cases  of  intracranial  sarcoma. 

^  Pepper's /System  o/i¥crficine,  vol.  v.,  p.  1017. 


OPERATIVE  TREATMENT.  249 

To  sum  up,  the  drug  treatment  of  intracranial  tumours  is  most 
unsatisfactory,  except  in  the  case  of  syphilitic  growths.  Iodide  of 
potassium  is  the  only  remedy,  so  far  as  we  at  present  know,  which 
is  likely  to  effect  much  benefit,  and  it  should  be  fairly  and  freely  tried 
in  all  cases,  whether  syphilitic  or  not,  in  which  drug  treatment  is 
indicated  or  is  likely  to  hold  out  any  prospect  of  success. 

Operative,  treatment. — The  brilliant  results  which  Macewen  has 
obtained  in  cerebral  surgery,  and  which  Victor  Horsley  has  recently 
published,  seem  to  prove  that  the  expectations  which  Hughes  Bennett 
formed  when  he  first  advocated  the  operation  were  well  founded. 
And,  thanks  to  antisepsis,  the  dangers  of  trephining  are  now  so  slight, 
that  in  all  cases  of  intracranial  tumour  in  which  substantial  improve- 
ment is  not  obtained  by  the  administration  of  iodide  of  potassium,  the 
possibility  of  removing  the  new  growth  by  operative  procedure  must 
be  carefully  considered. 

The  following  appear  to  me  to  be  the  most  important  conditions 
for  successful  operative  interference  : — 

(1.)  Satisfactory  localisation  of  the  tumour. — It  is  quite  obvious  that, 
in  the  absence  of  localising  symptoms,  it  may  be  impossible  to  come 
to  any  conclusion  as  to  the  position  of  the  new  growth.  Under  such 
circumstances,  if  the  symptoms  are  very  severe,  and  if  they  cannot 
be  relieved  in  any  other  way,  it  may  perhaps  in  some  cases  be 
advisable  to  trephine,  as  a  palliative  measure  {i.e.,  with  the  object  of 
giving  temporary  relief) ;  but,  in  the  absence  of  any  definite  know- 
ledge of  the  position  of  the  new  growth,  an  operation  for  its  removal 
is  of  course  contra-indicated. 

(2.)  The  tumour  must  he  accessible. — It  is  quite  obvious  that  the 
risks  attending  attempts  at  removal  of  tumours  in  some  situations, 
such  as  the  pons  A^arolii,  medulla  oblongata,  middle  lobe  of  the  cere- 
bellum, and  base  of  the  brain,  render  operative  procedure  quite 
impracticable. 

Tumours  in  the  motor  area,  both  because  of  the  exactness  with 
which  they  can  in  many  cases  be  localised,  and  the  facility  with  which 
they  can  be  reached,  offer  the  most  favourable  chance  of  removal 
by  operation. 

(3.)  The  tumour  must  he  si)igle,  and  of  such  a  pathological  character 
as  to  ijcrmit  of  complete  enucleation  or  removal. 


250  TREATMENT. 

In  the  case  of  multiple  tumours,  such  as  secondary  deposits  of 
cancer  or  melanotic  sarcoma,  operative  measures  for  the  removal  of  the 
tumour  are  of  course  quite  out  of  the  question.  Hence  the  great  import- 
ance of  exact  diagnosis,  not  only  as  regards  the  position  of  the  tumour, 
but  also  as  regards  the  pathological  character  of  the  new  growth. 

It  will  be  apparent  from  the  foregoing  statement,  that  in  some 
cases  the  position  of  the  tumour  cannot  be  satisfactorily  determined, 
that  in  others  it  is  so  situated  that  it  cannot  be  safely  and  satisfactorily 
operated  upon,  and  that  in  others  it  is  of  such  a  pathological  character 
that  it  cannot  be  completely  removed  by  means  of  operation.  Hence 
the  proportion  of  cases,  in  which  the  conditions  for  successful  removal 
and  cure  by  means  of  operation  are  present,  is  probably  not  great. 

On  the  other  hand,  it  must  be  remembered  that  in  the  great 
majority  of  cases  of  intracranial  tumour,  drugs  are  powerless  to  effect 
a  cure,  and  that  the  inevitable  termination,  if  left  alone,  is  (after  a 
longer  or  a  shorter  period,  which  is  often  attended  with  great 
suffering)  death. 

Further,  that  the  determination  of  the  exact  nature  and  extent  of 
the  tumour  by  means  of  the  symptoms  is  in  many  cases  impossible. 

Hence,  in  many  cases,  the  surgeon  is  justified,  if  iodide  of  potassium 
has  been  fairly  tried  and  has  failed,  in  operating,  provided  that  the 
tumour  can  be  localised,  and  that  its  position  does  not  preclude  suc- 
cessful operative  interference,  even  although  the  diagnosis  is  not  quite 
clear  on  the  other  points,  -i.e.,  as  regards  its  exact  pathological  nature 
and  extent. 

Kecent  surgical  experiences  have  shown  that  the  operation  of  tre- 
phining in  man  is  ])er  se  attended  with  comparatively  little  risk  to 
life  ;  while  experimenters  have  shown  that  in  the  lower  animals  enor- 
mous portions  of  the  brain  may  be  removed  without  causing  death. 
Provided  that  rigid  antiseptic  precautions  are  adopted, ^  there  is  reason 
t^  suppose  that  in  man  the  risks  of  removing  considerable  portions  of 
the  brain  are  very  much  less  than  was  at  one  time  thought  to  be  the 
case. 

Further  —  and   this   point   is   much   more  important   than   any 

^  A  comparison  of  the  results  obtained  by  Terrier  in  the  monkey,  without  and  with 
strict  antiseptic  precautions,  affords  to  my  mind  one  of  the  most  striking  proofs  which  has 
ever  been  advanced  of  the  inmiense  value  of  the  Listerian  method. 


TREATMENT.  251 

number  of  theoretical  considerations  —  Victor  Horsley  has  demons- 
trated that  some  cases  of  intracranial  tumour  in  man  can  be  satis- 
factorily dealt  with  in  this  manner. 

The  operation  of  trephining  may  perhaps,  in  some  cases — but 
only  when  the  symptoms  are  urgent  and  desperate,  and  when  other 
means  have  failed — be  advisable  as  a  palhative  measure.  In  one 
case  of  this  kind,  in  which  the  diagnosis  was  attended  with  great 
difficulty,  but  in  which,  so  far  as  I  could  judge  (and  I  was  confirmed 
in  this  opinion  by  Dr.  Hughlings  Jackson,  who  had  also  seen  the 
patient),  the  symptoms  were  due  to  an  organic  cerebral  lesion,  pro- 
bably a  tumour,  the  operation,  which  was  performed  by  Dr.  Caird, 
has  been  so  far  attended  with  marked  relief.  I  repeat  that  trephining, 
as  a  palliative  measure,  is  only  in  my  opinion  justifiable  when  the 
symptoms  are  desperate,  and  when  other  means  have  failed  to 
give  relief. 

Palliative  Measures. — For  the  relief  of  pain,  morphia — particularly 
in  the  form  of  subcutaneous  injections, — Indian  hemp,  and  croton 
chloral,  free  watery  purgation,^  the  administration  of  remedies,  such 
as  iodide  of  potassium  and  the  nitrites,  which  reduce  blood-pressure, 
and  the  application  of  cold  in  tlie  form  of  ice-bags"  to  the  head — 
are,  in  my  experience,  the  most  useful.  Ergot  of  rye,  which  has  been 
recommended  by  some  writers  for  the  relief  of  headache,  has  not  in 
my  hands  yielded  any  beneficial  results. 

For  the  relief  of  spasms  and  epileptiform  convulsions,  bromide  of 
potassium  and  chloral  hydrate  are  the  chief  remedies.  Localised 
spasms  or  attacks  of  Jacksonian  epilepsy,  due  to  syphilitic  deposits 
on  the  surface  of  the  motor  area,  are  best  treated  by  large  doses  of 
iodide  of  potassium ;  when  very  severe,  chloral  hydrate,  or  bromide  of 
potassium  and  chloral  hydrate,  may  be  given,  with  the  object  of  re- 
straining the  epileptic  seizures  until  the  iodide  has  time  to  exert  its 
specific  effects. 

Apoplectic  attacks  due  to  hsemorrhagic  extravasation  are  to  be 
treated  in  the  same  way  as  ordinary  apoplexies. 

^  The  marked  benefit  which  in  some  cases  follows  free  purgation  is  well  exemplified 
in  a  case  which  I  have  reported  in  the  Edinburgh  Medical  Journal  for  February  1887, 
p.  688. 

^  In  a  case  of  cerebellar  tumour,  which  I  have  recorded  in  the  Edinburgh  Medical 
Journal  for  June  1879,  p.  1073,  the  patient,  a  girl  aged  nine,  found  out  for  herself  that 
the  application  of  cold  to  the  head  relieved  the  headache.  Her  mother  stated  that  the 
patient  used  to  stand  for  half  an  hour  at  a  time  with  her  head  under  the  cold  tap. 


252  TREATMENT. 

In  pseudo-apoplectic  attacks,  the  application  of  cold  to  the  head, 
blistering,  free  purgation,  or  venesection,  are  the  best  remedial 
measures. 

The  paralyses  which  are  caused  by  intracranial  tumours  must  be 
treated  in  the  same  manner  as  the  paralyses  due  to  other  lesions. 
Epileptiform  paralysis  rapidly  disappears,  provided  that  the  localised 
convulsive  seizures  with  which  it  is  associated  can  be  relieved  by 
appropriate  treatment.  As  already  stated,  iodide  of  potassium  is  the 
remedy  which  is  most  likely  in  such  cases  to  afford  permanent  relief. 

Paralysis  due  to  a  syphilitic  lesion  of  a  nerve  trunk  should  be 
treated,  in  its  earlier  stages,  by  large  doses  of  iodide  of  potassium 
alone,  or  in  combination  with  mercury.  In  the  later  stages  of  cases 
of  this  description,  and  after  the  system  lias  been  thoroughly  saturated 
with  the  iodide,  I  have  found  strychnine,  arsenic,  and  electricity 
beneficial. 

In  all  cases  of  intracranial  tumour  in  which  double  optic  neuritis 
is  developed,  the  administration  of  iodide  of  potassium  is  advisable. 
Under  tliis  treatment  the  inflammation  of  the  optic  papilla  is,  in  some 
instances,  reduced  or  altogether  relieved,  and  the  occun-ence  of  post- 
neuritic atrophy  and  blindness  thereby  prevented.  Even  wlien  the 
optic  neuritis  is  so  intense  as  to  produce  complete  blindness,  the  most 
marked  improvement  may  take  place  under  this  treatment.  Dr. 
Hughlings  Jackson,  for  example,  states  that  "  it  is  well  known  that 
optic  neuritis  may  pass  off  under  treatment,  leaving  good  sight, 
whether  there  has  been  a  defect  of  sight  or  not, — even  when  there  has 
been  complete  blindness." 

Such  marked  improvement  is  probably  only  to  be  hoped  for  in 
syphilitic  cases  ;  for  other  forms  of  tumour,  with  such  intense  optic 
neuritis,  are  usually  fatal.  On  this  point  I  am  disposed  to  agree 
with  Dr.  Buzzard,  who  states  "  that  he  did  not  think  that  he  had 
ever  seen  atrophy  of  the  disc  ensue  in  any  case  of  optic  neuritis 
accompanying  syphilitic  disease  of  the  brain  in  which  specific  treat- 
ment had  been  adopted  before  there  was  any  failure  of  sight.  On  the 
other  hand,  he  did  not  feel  thoroughly  satisfied  that  he  had  often  seen 
successful  treatment  of  swollen  discs  by  iodide  or  mercury  in  a  case 
where  a  syphilitic  element  was  not  probably  present."  ^ 

^   Transactions  of  the  OpMhalmological  Society  of  tlic  United  Kingdom,  vol.  i.,  p.  99. 


TREATMENT.  253 

But  it  is  of  the  greatest  importance  to  recognise  the  facts  that  the 
most  marked  improvement  may  occur  even  when  the  papillitis  is 
intense ;  and  that,  with  the  object  of  preventing  post-neuritic  atrophy 
and  blindness,  iodide  of  potassium  should  be  freely  administered  as 
soon  as  the  inflammatory  changes  in  the  fundus  are  recognised. 

It  is  unnecessary  to  refer  to  the  treatment  of  bed  sores,  cystitis, 
and  other  complications  and  associated  lesions. 

The  external  localisation,  or  the  method  which  is  to  be  adopted  in 
order  to  ascertain  the  exact  point  on  the  surface  of  the  scalj)  which 
corresponds  to  any  given  portion  of  the  cortex  of  the  brain  under- 
neath, together  with  the  surgical  details  which  it  is  advisable  to  adopt 
in  performing  the  operation  for  the  removal  of  brain  tumours,  are 
described  in  the  following  chapter,  which  Mr,  Hare,  whose  work  in 
this  department  is  well  known,  has  been  so  kind  as  to  write  for  me. 


CHAPTER    XL 

THE  SURGICAL  TEEAT:MEIs^T  OF  II^TRACRAXIAL  TUMOUES. 
By  Arthub  W.  Hare,  RR.C.S.Ed. 

I.  There  are  certain  regions  within  the  cavity  of  the  skull  that  have 
been  recently  brought  within  the  bounds  of  legitimate  surgical  inter- 
ference for  the  presence  of  neoplasms  and  inflammatory  accumulations. 
Tumours  of  the  meninges,  for  the  most  part  originating  in  cicatricial 
tissue  following  an  injury,  and  tumours  of  the  cortical  substance  itself, 
are  now  successfully  removed  by  the  surgeon ;  and  circumscribed  areas 
of  suppuration  in  each  of  these  positions,  and  in  the  interior  of  the 
brain,  have  been  repeatedly  operated  on  with  success.  As  yet  these 
must  constitute  the  limits  of  legitimate  operative  interference,  if  the 
statistics  of  recorded  cases  are  to  be  relied  on ;  for  the  attempts  that 
have  been  made  to  add  diffuse  suppuration,  deep-seated  tumours,  and 
localised  idiopathic  haemorrhages  to  the  category  of  operable  affections 
have  not  been  attended  with  encouraging  results.  Of  the  deep- 
seated  tumours,  those  of  the  cerebellum  seem  least  certainly  included 
in  this  prohibition,  for  the  objection  in  their  case  is  the  technical 
difficulty  of  the  operative  procedure,  rather  than  the  physiological 
contra -indications  that  apply  in  the  case  of  deep-seated  growths 
of  the  cerebrum. 

II.  Having  defined  in  this  way  the  scope  of  operative  surgery,  as 
at  present  practised,  in  the  region  of  the  cranium  for  idiopathic 
lesions,  it  is  important  to  consider  the  chief  structural  features  of 
that  region  to  wliich  the  surgeon  must  have  regard  in  planning  his 
remedial  operations. 

In  the  preceding  chapters  the  study  of  localised  function  in  the 
brain,  and  the  light  thrown  thereby  on  the  delimitation  of  localised 
lesions,  have  been  fully  referred  to;  and  it  is  now  important  to 
inq^uire  in  how  far  this  field  of  knowledge  may  be  available  for  the 
purposes  of  defining  the  exact  situations  in  which  surgical  interference 


ANATOMICAL  FEATURES.  255 

must  be  undertaken.  For  this  purpose  it  is  necessary  to  define,  within 
the  limits  of  approximate  accuracy,  the  anatomical  relation  of  various 
areas  of  the  cerebral  cortex  to  constant  external  landmarks  on  the 
surface  of  the  head.  Some  satisfactory  and  practically  useful  method 
of  defining  these  important  relations  must  be  discovered,  if  possible, 
which  shall  not  involve  a  preliminary  reflection  of  the  scalp,  before  it 
can  be  applied,  since  the  appropriate  treatment  of  the  scalp  itself,  and 
its  careful  protection  during  an  operation,  are  of  the  greatest  conse- 
quence in  securing  success  in  every  case  of  surgical  interference  with 
the  head.  A  system  solely  founded  on  the  recognition  of  surface 
markings  on  the  bones  of  the  head  will  therefore  prove  unsatisfactory, 
where  exact  precision  is  so  all-important.  It  is  true  that  it  may  render 
confirmatory  information  to  the  surgeon  during  the  course  of  his 
operation,  but  the  primary  data  on  which  he  must  rely  are  such  as  he 
can  determine  with  all  the  cranial  coverings  still  intact.  For  this 
reason  the  cranial  sutures  must  be  left  out  of  count,  since  they  are 
not  accurately  discernible  in  the  living  subject,  and  a  practical 
method  must  be  established  on  the  topographical  relations  of  bony 
eminences  which  are  always  available  for  the  purpose,  and  give 
sufficient  accurate  information  on  the  point  at  issue.  Before  selecting 
those  landmarks  which  are  of  actual  value  for  this  purpose,  it  is 
necessary  to  exclude  all  such  bony  prominences  as  have  no  constant 
and  essential  relation  with  one  or  other  region  of  the  cranial  cavity. 
Further,  those  selected  must  bear  an  uniform  relation  to  the  brain- 
case  as  a  whole,  irrespective  of  varying  degrees  of  relative  individual 
development  in  the  bones,  of  which  they  form  a  part.  That  bony 
prominences  of  the  facial  region  must  be  absolutely  excluded  from 
the  calculation,  on  account  of  their  unequal  development  in  relation 
to  the  cranium  in  different  races  and  in  different  individuals  of  the 
same  race,  is  sufficiently  shown  by  the  classic  researches  of  Camper 
on  the  varieties  of  the  facial  angle  as  affecting  physiognomy.  If  it 
be  somewhat  less  obvious,  it  is  equally  important  to  notice  that  bony 
landmarks  of  the  lower  segments  of  the  skull  itself  must  be  for  a  like 
reason  discarded,  since  they  give  no  accurate  basis  for  a  system  of 
mapping  out  the  surface  of  the  head  in  relation  to  the  underlying 
regions  of  the  cortex.  If,  for  instance,  the  external  auditory  meatus 
or  the  mastoid  process  be  employed  for  such  a  purpose,  the  lines 


2s6  CRANIAL  LANDMARKS. 

traced  from  them  upwards  over  the  vault  will  give  iaconstant  results, 
according  as  the  frontal  zone  and  the  anterior  fossa,  or  the  occipital 
zone  and  the  posterior  fossa,  are  severally  more  or  less  developed  at 
the  expense  of  the  parietal  zone  and  the  middle  fossa,  to  which  alone 
such  measurements  can  accurately  apply.  The  comparison  of  a  well- 
marked  dolicocephalic  cranium  with  one  of  a  brachycephalic  type,  in 
regard  to  the  relative  development  of  these  three  zones  or  segments, 
shows  clearly  to  how  great  an  extent  such  a  system  is  calculated  to 
mislead  the  surgeon.  If  these  outstanding  landmarks  be  left  out  of 
account  for  the  reasons  just  stated,  it  will  be  found  that  enough  still 
remain  for  the  construction  of  a  clear  and  sufficiently  precise  method 
of  localisation.  Four  bony  prominences  of  the  cranium  proper  are 
particularly  of  value.  These  are — (1.)  The  glabella,  or  root  of  the 
nose,  which  bears  a  definite  relation  to  the  anterior  limit  of  the 
cranial  cavity.  (2.)  The  occipital  protuberance  or  inion,  which  bears 
a  similar  relation  to  the  posterior  extremity  of  the  cerebral  receptacle, 
and  to  the  upper  limit  of  that  containing  the  cerebellum,  since  it 
marks  the  point  of  junction  of  the  falx  with  the  tentorium.  Between 
these  two  poles  of  the  vault,  is  disposed  the  whole  mass  of  the  cere- 
brum, and  their  surface  distance  apart,  on  the  vertex,  is  definitely 
related  to  the  mesial  surface  measurement  of  the  whole  arc  of  the 
cerebrum.  With  an  immaterial  correction  for  varying  thickness  of 
the  skull  and  scalp,  this  mesial  surface  measurement  from  glabella 
to  inion  bears  a  constant  relation  to  the  corresponding  cerebral 
measurement,  unaffected  by  the  varied  relative  expansion  of  the 
individual  bones  of  the  vault,  that  is  found  to  exist  in  all  human 
beings.  (3.)  The  external  angular  process  of  the  frontal  bone  is  the 
third  bony  point  that  affords  reliable  evidence  on  the  principle 
already  defined.  It  bears  a  definite  relation  to  the  antero-lateral 
extremity  of  the  frontal  lobe,  and  to  the  point  of  origin  of  the  fissure 
of  Sylvius ;  since  it  marks  the  plane  of  the  floor  of  the  anterior  fossa, 
the  posterior  limit  of  which  corresponds  to  the  interval  between  the 
frontal  and  temporo-sphenoidal  lobes.  (4.)  Lastly,  the  parietal  emi- 
nence is  of  similar  value,  since  it  marks  the  point  of  greatest  lateral 
expansion  of  the  substance  of  the  hemisphere.  Though  its  distance 
from  the  vertex  varies  greatly  in  different  heads,  and  its  relation  to 
other  bony  points,  and  even  to  the  bone  of  which  it  is  a  part,  are  not 


CRANIO-CEREBRAL  LOCALISATION.  257 

uniform,  it  is  still,  as  has  been  shown  by  Turner,  a  useful  landmark. 
Its  cerebral  relations  are  much  more  constant  than  its  cranial  relations, 
and  it  is  on  that  account  of  special  value  for  the  purposes  of  localising 
the  position  of  cortical  areas. 

III.  With  these  anatomical  data  to  work  upon,  the  first  object  is 
to  define  the  position  of  the  primary  fissures  of  the  brain  in  relation 
to  the  surface  of  the  head.  The  fissure  of  Eolando  claims  the  first 
place,  inasmuch  as  those  areas  of  functional  representation  associated 
with  motor  phenomena  are  grouped  around  it,  and  are  the  most 
accurately  defined  of  all  the  cortical  areas  concerned  in  localised 
function.  To  define  the  upper  end  of  the  fissure,  where  it  joins  the 
great  longitudinal  fissure,  the  surface  measurement  of  the  scalp 
should  be  taken  in  the  middle  line  from  the  glabella  to  the  external 
occipital  protuberance.  In  ordinary  adult  heads  this  will  vary  from 
eleven  to  thirteen  inches.  Measured  from  before  backwards  along 
this  line,  the  distance  from  the  glabella  to  the  top  of  the  fissure  is  55 "7 
per  cent,  of  the  length  of  the  whole  line.  The  following  sliding  scale 
shows  the  distance  from  the  glabella  to  the  top  of  the  fissure  in  heads 
of  ordinary  size  : — 

Distance  from  glabella  to  Distance  from  glabella  to 

occipital  protuberance.  top  of  fissm'e  of  Rolando. 

In  a  head  of  11  inches,      .  .  .         6-j3g-  inches. 


\\\ 
12 
12i 
13 


6f 
6f 

7 

74 


This  scale  is  based  on  a  series  of  observations  made  on  a  number 
of  perfectly  fresh  trunkless  heads,  treated  by  a  special  method  in- 
tended to  conserve  the  proper  anatomical  relation  of  parts,  while 
giving  evidence  on  this  important  cranio-cerebral  relation.  Eleven 
heads  of  greatly  varying  type  and  proportion  were  employed  in 
elaborating  this  uniform  scale,  and  as  it  was  found  reliable  in  cases 
of  extreme  variation,  it  will  apply  even  more  accurately  to  heads  of 
ordinary  shape.  It  depends  for  its  accuracy  upon  the  fact  that  the 
pre-Eolandic  and  post-Eolandic  regions  of  the  brain  bear  in  general  a 
uniform  proportion  to  one  another  as  regards  extent,  irrespective  of  the 
size  of  the  brain  as  a  whole.     The  pre-Eolandic  arc  is  thus  a  definite 


258  METHOD  OF  LOCALISATION. 

fraction  of  the  whole  arc  of  the  brain  surface,  measured  in  the  mesial 
plane ;  and  that  fraction  has  been  defined  by  the  measurements  referred 
to  as  ■557  of  the  whole  arc.  The  whole  cerebral  arc  is  represented  on 
the  surface  of  the  scalp  by  the  whole  line  from  the  glabella  to  the 
inion,  and  the  pre-Eolandic  arc  is  similarly  represented  on  the  surface 
by  the  anterior  '557  of  that  line.  Thus  an  exact  scale  based  on  this 
fractional  relationship  can  be  established  applicable  to  any  head.  Pro- 
fessor Thane,  of  University  College,  London,  advocates  a  modification  of 
this  method.  He  halves  the  distance  from  the  glabella  to  the  inion, 
and,  having  thus  defined  the  middle  of  the  vertex,  takes  a  point  half 
an  inch  behind  it  as  the  top  of  the  fissure.  This  is  not  so  accurate  as 
a  sliding  scale,  but  is  sufficiently  so  for  practical  purposes  in  ordinary 
heads ;  and,  as  such,  it  is  to  be  recommended  as  the  most  ready  and 
convenient  method  in  the  majority  of  cases;  while  for  unusually 
small  or  large  heads  a  fresh  calculation  should  be  made  on  the  data 
above  given. 

The  localisation  of  the  upper  end  of  the  fissure  in  the  middle  line 
of  the  scalp  is  by  no  means  sufficient  for  practical  purposes ;  for 
it  is  no  less  essential  to  be  able  to  map  out  its  extent  and  direction. 
The  average  measurement  on  the,  scalp  corresponding  to  the  distance 
between  its  extremities  (leaving  out  of  account  its  two  curves)  is  3f 
inches  in  medium-sized  heads,  and  its  direction  is  from  above  do'OTi- 
wards  and  forwards.  The  long  axis  of  the  fissure  forms,  with  the 
mesial  line,  an  angle  of  67°,  the  angle  opening  forwards.  To 
give  practical  value  to  the  foregoing  facts,  an  instrument  has  been 
devised,  at  the  suggestion  of  Professor  Chiene,  by  Dr.  Claude  "Wilson 
of  Tunbridge  Wells.  It  combines  with  the  scale  of  measurements 
for  localising  the  fissure  those  data  representing  its  length  and 
direction  (see  Fig.  114).  The  mode  of  its  application  to  a  patient's 
head  is  shown  in  Pig.  115.  In  coincidence  with  Professor  Chiene's 
object  in  suggesting  its  construction,  the  instrument  can  be  applied 
to  a  patient  in  the  recumbent  posture,  as  is  often  essential  in  cases 
w^here  operation  is  necessary. 

This  instrument  is  extremely  simple  in  its  structure,  consisting 
merely  of  three  strips  of  flexible  metal,  and  a  tape  for  securing  them 
in  position  on  the  patient's  head.  In  its  application  the  broadest 
transverse  strip  is   applied  circumferentially  around   the   head,  em- 


WILSON'S  INSTRUMENT. 


259 


bracing  the  glabella  and  the  external  angular  process  in  the  frontal 
region,  and  being  firmly  secured  at  the  occipital  protuberance  by- 
means  of  the  tape  attached  to  the  eyelet  of  the  strip.  A  narrower 
longitudinal  strip  of  metal  attached  to  the  first  strip  at  a  right  angle 


Fig.  114. — Wilsons  Cyrtometer. 

passes  backwards  in  the  middle  line  over  the  scalp  to  the  occipital 
protuberance.  This  strip  is  marked  with  two  series  of  letters : 
capitals  near  its  occipital  end,  small  letters  about  the  middle  of  the 
strip.     These  two  series  of  letters  are  related  to  one  another,  each  to 


26o 


APPLICATION  OF  METHOD. 


each,  as  '557  is  to  unity,  measuring  from  the  frontal  end  of  the  strip. 
Hence,  when  any  given  capital  letter  on  the  strip  falls  upon  the 
prominence  of  the  inion,  the  corresponding  small  letter  points  out  the 
upper  limit  of  the  fissure  of  Eolando  in  that  particular  head.  A 
third  narrow  reversible   slip   glides  forwards  or   backwards  on  the 


// 


\<- 


is"/  ' 


Fig.  115. — Wilson's  Cyrtometer  hi  situ.  G,  glabella  ;  E  A  P,  external 
angular  process  ;  R,  fissure  of  Rolando — its  position  and  direction  marked 
by  the  lateral  strip  of  metal. 

longitudinal  strip,  and  marks  an  angle  of  67°,  opening  forwards,  thus 
giving  the  axis  of  the  fissure.  Thus  its  direction  and  length  can  be 
ascertained  on  any  head  as  above  defined. 

The  fissure  of  Sylvius  has  definite  relations  both  to  external  land- 
marks of  the  head  and  to  markings  on  the  surface  of  the  skull,  which 


CRANIO-CEREBRAL  TOPOGRAPHY.  261 

enable  the  surgeon  to  localise  its  position  prior  to  operative  inter- 
ference, and  to  confirm  his  view  of  its  locality  during  the  early  stages 
of  the  operation.  To  define  its  position,  a  line  is  drawn  from  the 
external  angular  process  of  the  frontal  bone  backwards  to  the 
occipital  protuberance,  taking  the  nearest  route  between  those  two 
prominences.  Such  a  line  droops  a  little  towards  the  external 
auditory  meatus,  in  avoiding  the  greater  convexity  of  the  side  of 
the  skull  that  lies  in  the  direct  horizontal  route  between  the  two 
bony  eminences  {EAP-OPr,  Fig.  116).  It  usually  passes  over 
the  temporal  bone  half  an  inch  above  the  meatus,  at  which 
place  it  corresponds  to  the  floor  of  the  middle  fossa  of  the  base 
of  the  skull.  1  In  front  of  the  meatus  it  is  above  the  floor  of  the 
middle  fossa ;  and  behind,  it  runs  parallel  to,  and  usually  coincident 
with,  the  attachment  of  the  tentorium  and  the  posterior  half  of  the 
lateral  sinus.  A  measurement  of  1|  inch  backwards  from  the  angular 
process  along  this  important  line  gives  the  point  of  origin  of  the 
fissure  of  Sylvius.  From  this  point  a  straight  line  drawn  to  the 
centre  of  the  parietal  eminence  marks  accurately  the  course  of  the 
posterior  limb  of  the  fissure.  On  reflecting  the  skin  and  the  temporal 
fascia  and  muscle,  the  surgeon  will  find  the  pterion  (Fig.  116),  or 
junction  of  the  sphenoid  with  the  frontal,  parietal,  and  temporal 
bones.  From  its  point  of  origin  under  the  great  wing  of  the  sphenoid, 
the  main  line  of  the  Sylvian  fissure  follows  that  of  the  squamo- 
parietal  suture  to  its  highest  point,  from  which  the  fissure  diverges 
upwards,  continuing  its  course  to  the  parietal  eminence.  The 
ascending  limb  of  the  fissure,  or  precentral  sulcus,  corresponds  closely 
with  the  upper  part  of  the  sphenoido-squamosal  suture,  the  line  of 
which  it  continues  upwards  for  half  an  inch,  giving  off  the  inferior 
frontal  sulcus  at  right  angles  near  its  upper  extremity.  An  im- 
portant anatomical  detail  of  this  region,  which  the  surgeon  does  well 
to  keep  in  mind,  is  tliat  the  middle  meningeal  artery,  after  grooving 
the  under  surface  of  the  great  wing  of  the  sphenoid,  passes  on  to  the 
anterior  inferior  angle  of  the  parietal,  and  is  distributed  to  the  dura 

^  This  point  is  of  special  importance  to  the  surgeon,  since  it  has  been  pointed  out  by 
Dr.  M 'Bride  and  Mr.  Miller  that  this  is  the  proximal  route  to  adopt  in  the  evacuation  of 
intracranial  abscesses  originating  in  the  tympanum.  The  roof  of  the  tympanum,  which  is 
usually  perforated  in  these  conditions,  is  here  most  easily  reached,  and  the  pus  thus  inter- 
cepted and  evacuated  at  its  source  of  origin. 


262 


EXTERNAL   CEREBRAL  RELATIONS. 


mater  liuing  the  anterior  and  superior  half  of  that  bone  (Fig.  116). 
If  he  desire  to  expose  the  tip  of  the  temporo-sphenoidal  lobe,  he 
should  trephine  below  and  behind  the  line  of  the  artery ;  if  to  cut 
down  on  Broca's  convolution,  immediately  in  front  of  the  same  line. 


FR 


POE 


Fig.  116. — Head,  skull,  and  cerebral  fissures  (adapted  from  Marshall). 
0  Pr,  occipital  protuberance  ;  E  A  P,  external  angular  process  ;  <S'  F,  Sylvian 
fissure  ;  J ,  its  ascending  limb  ;  F  R,  fissure  of  Kolando  ;  P  E,  parietal 
eminence;  MM  A,  middle  meningeal  arterj-;  T  S,  tip  of  temporo-sphenoidal 
lobe  ;  B,  Broca's  convolution  ;  /  F,  inferior  frontil  sulcus  ;  P  0  F,  parieto- 
occipital fissure  ;  I  P  F,  intra-parietal  sulcus.  The  pterion  region  is  that 
where  tlrree  sutures  meet  ; — those  bounding  the  great  wing  of  the  sphenoid 
where  it  joins  the  frontal  parietal  and  temporal  bones. 

To  define  the  position  of  the  remaining  sulci  of  the  brain,  the 
two  primary  fissures  must  be  mapped  out  on  the  scalp  as  already 
described.  Then  the  parieto-occipital  fissure  will  be  at  a  point  two 
inches  beliind  the  upper  end  of  tlie  Kolandic  fissure ;  and  when  the 


METHOD  OF  OPERATING.  263 

scalp  is  reflected,  that  point  will  be  found  to  be  placed  a  quarter  to 
half  an  inch  in  front  of  the  apex  of  the  lambdoidal  suture.  The 
fissure  is  about  one  inch  in  length,  running  at  right  angles  with  the 
the  great  longitudinal  fissure  with  which  its  upper  extremity  is 
continuous. 

The  intra-parietal  sulcus  commences  one  inch  posterior  to,  and  at 
the  level  of,  the  middle  third  of  the  fissure  of  Eolando,  having  the 
ascending  parietal  convolution  between  it  and  that  fissure.  It  runs 
upwards  and  backwards  for  about  an  inch,  and  then  turns  directly 
backwards,  forming  the  lower  boundary  of  the  superior  parietal 
lobule.  Then,  passing  below  the  outer  extremity  of  the  parieto- 
occipital fissure,  it  enters  the  occipital  lobe,  in  which  it  terminates. 

IV,  In  describing  the  operative  procedure  for  the  removal  of  intra- 
cranial neoplasms,  it  is  well  to  follow  the  rules  laid  down  by  Professor 
Victor  Horsley,  the  able  exponent  and  brilliant  exemplar  of  successful 
procedure  in  this  department  of  operative  surgery.  Eigid  asepticity 
is  essential,  and  is  secured  by  a  searching  preliminary  purification  of 
the  scalp,  and  the  employment  of  complete  antiseptic  measures  and 
the  carbolic  spray  during  the  operation.  The  scalp  wound  is  cres- 
centic  in  shape,  and  of  large  dimensions,  the  soft  parts  being  turned 
freely  back  from  the  area  of  the  operation.  Trephines  of  large  size 
are  used,  two  contiguous  circles  of  bone  being  removed,  and  the 
isthmus  of  bone  between  them  sawm  through,  so  as  to  make  one  large 
aperture  in  the  skull.  The  fragments  of  bone  are  carefully  preserved 
in  warm  antiseptic  cloths,  and  are  chipped  up  and  replaced  at  the  end 
of  the  operation  according  to  Macewen's  method.  A  white  sliimmer- 
ing  through  the  dura  and  a  lack  of  pulsation  indicate  that  the  position 
of  the  tumour  has  been  correctly  diagnosed.  The  dura  is  incised, 
and  the  tumour  removed  with  a  sharp  scalpel  if  firm,  or  with  a  spoon 
if  soft  or  friable,  the  haemorrhage  being  reduced  by  the  preliminary 
exhibition  of  morphia  to  reduce  cerebral  congestion,  and  controlled 
locally  by  the  pressure  of  sponges.  When  it  has  ceased,  the  dura  is 
stitched  with  catgut,  the  fragments  of  the  cranial  bones  returned,  and 
the  scalp  very  accurately  stitched.  ISTo  drain  is  placed  in  the  wound, 
which  is  carefully  dressed  and  accurately  bandaged,  so  as  to  secure 
steady  and  eq^uable  pressure.  Primary  union  is  looked  for;  and 
should  it  not  occur,  or  should  hernia  cerebri  ensue,  a  failure  in  the 


264  METHOD  OF  OPERATING. 

aseptic  precautions  is  betokened.  Should  there  be  tension,  a  strictly 
purified  probe  is  introduced  at  a  remote  angle  of  the  scalp  wound, 
and  the  escape  of  a  little  serum  permitted.  This  is  usually  sufficient 
to  ensure  satisfactory  healing,  in  Professor  Horsley's  experience. 

If  the  operation  be  for  abscess,  the  cause  is  not  infrequently 
septic  bone  disease.  In  tliis  case,  after  evacuating  the  contents, 
efficient  drainage  must  be  maintained  by  a  rubber  drainage  tube,  and 
the  abscess  cavity  washed  out  daily  with  a  weak  antiseptic  lotion,  till 
contraction  and  healing  ensue,  or  till  the  discharge  becomes  odourless, 
when  the  daily  dressing  and  irrigation  may  be  omitted. 

In  all  cases  of  operation  on  the  cranium,  the  general  treatment 
requires  no  less  attention  than  the  local ;  and,  if  possible,  all  patients 
should  be  subjected  to  preparatory  treatment  and  observation  before 
an  operation  is  undertaken. 


INDEX. 


I  N  D  E  X. 


PAGE 

Abscess,  Differential  Diagnosis  from 

Tumour,     .         .         .         .         .  141 
Age,  Influence  of,            .          .          -4,  201 

Agraphia,       .         .         .         .         .  116 

Albuminuria,           .          .                    .  121 

Albuminuric  Retinitis,    .          .          .  125 

Alcoholic  Excess,  as  a  cause  of  Tumour,  3 
Alternate  Hemiplegia — Set  Hemiplegia. 

Alveolar  Sarcoma,           .         .         .  236 

Amblyopia,    .          .          .          .          .  157 
Ansemia,  Differential  Diagnosis  from 

Tumour, 130 

Anaesthesia,    .....  88 

,,           Diagnostic  Value  of,     .  90 

Analysis  of  Symptoms,    ...  25 

Aneurism  of  Cerebral  Vessels,          .  161 
Anxiety  and  Worry,  a  possible  cause 

of  Tumour,          .         .         .         .  3 
Aphasia,         .         .         .           115,  116,  154 

Aphemia,        .....  116 

Apoplectic  Attacks,         .         .         .  117 

,,             Treatment  of,        .  251 
Pseudo-  117,145,202,252 

Appetite,  Voracious,       .         .         .  119 
Artery,  Middle  Meningeal,      .           261,  262 

Ascending  Limb  of  Sylvian  Fissure,  261 

Ataxia,  Cerebellar,          .         .         .  188 

Atrophy  of  the  Brain,     ...  42 
,,                 ,,         Differential    Diag- 
nosis from  Tumour,  131 
,,        of  the  Optic  Discs — Set  Optic 
Atrophy. 

Auditory  Centre,    .          .          .          .  102 

Aura,  Diagnostic  Value  of,      .         .  102 

,,     Visual,           ....  102 

Basal  Ganglia,  Tumours  of,    .         .  171 

Base  of  the  Brain,  Tumours  of,       .  161 

,,                 Anterior  Region,  161 

„                 Middle         „  169 

,,                 Posterior      ,,  170 

Bastian,  Prof.  H.  Charlton,     .         .  90,  116 

Bed-Sores, 121 

Bennett,  Dr.  A.  Hughes,         .         .  249 

Prof.  J.  Hughes,       .          .  19 

Berry,  Dr.  G 179 

Bladder,  Derangements  of,      .          .  87 

BKndness,  Sudden,          ...  93 
Bright's  Disease,  Differential  Diagnosis 

from  Tumour,     .         .         .         .  125 

Bristowe,  Dr 160 

Broadbent,  Dr.  S.  W.     .        23,  51,  57,  130 

Broca's  Convolution,  Locality  of,    .  262 

Bulbar  Symptoms,           .         .         .  186 

Buzzard,  Dr.           .         .         .39,  66,  252 


PAGE 

Caird,  Dr 249 

Camper's  Observations,  .         ,         .         255 
Cancerous  Tumours,        .         .  235,  239 

, ,  Diagnostic  Features  of,  240 

Centres,  Motor — See  Motor  Centre. 

,,        Visual,      ....  97 

Centrum  Ovale,  Tumours  of,  .         .         159 
Cerebellar  and  Cerebral  Abscess,  Diffe- 
rential Diagnosis  from  Tumour,  141 
,,       Ataxia,      ....         188 
,,       Gait,  ....         188 

Cerebellum,  Symptoms  due  to  Lesions  of,  191 
,,  Tumours  of,         .         .         187 

,,  ,,  Differential 

Diagnosis  of,  .         .         197 

Cerebral  Atrophy,  ...  42 

,,        Hemorrhage,  .  143,  145 

,,  ,,  Xo  Neuritis  in,        60 

Cerebro- Spinal  Sclerosis,  Differential 

Diagnosis  from  Tumour,       .  .  197 

Cheyne- Stokes  Respiration,      .  121,  186 


Chiene,  Prof. 

258 

Cholesteatomata,     . 

240 

Choreic  Spasms, 

86 

Circus  Movements, 

86 

Clinical  Types  of  Tumour, 

19 

Clonic  Spasms — Stt  Convulsions. 

Clouston,  Dr. 

167 

Compensation    after    Destruction 

"of 

Motor  Centre,     . 

9 

Conjugate  Deviation  of  the  Eyes 

and 

Head,          .... 

185 

Coutractiu'e,  .... 

86 

Convulsions,  Epileptiform, 

.      7 

8,83 

,,              Causes  of, 

.     7 

8,80 

,,              Characters  of. 

79 

,,             Diagnostic  Value  of. 

.    82,  84 

,,             Local, 

79 

Tonic, 

'  85 

193 

,,              Treatment  of. 

251 

Corpora  Quadrigemiua,  Tumours  of. 

175 

Corpus  Callosum,  Tumours  of. 

160 

,,       Striatum,          ,, 

172 

Cranial  Landmarks, 

256 

,,       Sutures, 

255 

Cranio-Cerebral  Localisation, 

257 

, ,              Topography, 

261 

Cured  Tumours, 

244 

Cyrtometer,  Wilson's,     .          258, 

259 

260 

Deafness,        .         .         .  169,  184,  194 

,,         Sudden,  ....  93 

Death,  Causes  of,  .         .         .         .         247 

„       Sudden,       .         .         .  244,  247 

Deiter's  Cells,  Enlargement  of,      7,  49,  214 


268 


INDEX. 


Descending  Neuritis,  Thedi-y  of  Optic 

Neuritis,     .....  63 

Destroying  Lesiou.s,         ...  9 
Deutschmann,  Prof.        .          47,  51,  55,  64 

Diabetes  Insipidus  and  Mellitus,      121,  165 

DiagTiosis  of  Tumour,     .         .         .  122 
,,         Differential — Sec  Differen- 
tial Diagnosis. 

Difficulty  of,  .         .     23,  24,  122 


Importance  of  Exact, 
,,         Local, 
,,         Pathological,  . 
,,         Sources  of  EiTor, 
Differential  Diagnosis,    . 

, ,  of  Cerebral  Tumour 


2 
146 
199 
146 
123 

130 


and  Anajmia, 
,,  ofCerebralTumour 

and  Atrophy  of  the 
Brain,     . 
,,     ,  Bright's  Disease,  123 

„  Cerebral  Abcess,  141 

,,  Cerebral  Hemor- 

rhage,       143,  145 
,,  Cerebro  -  Spinal 

Sclerosis, . 
,,  Extracranial 

Syphilis,   . 
,,  Hypermetropia, 

,,  Hysteria, 

, ,  Insanity, 

,,  Lead  Encephalo- 

pathy, 
„  Meniere's    Dis- 

ease, 
,,  Meningitis,  . 

, ,  ]Migraine, 

Diffuse  Irritative  Changes,      .         .       7 
Discharging  Lesions, 
Drainage  in  Operations, 
Dropsy  of  the  Ventricles,  Production  of, 
Drummond,  Dr.  D. 
Duration  of  Intracranial  Tumours, 


131 


197 

143 
130 
133 
136 

127 

197 
136 
132 
,49 
9 
263 
195 
203 
204 


Edmunds,  Dr 45 

Emaciation,   ....  119,  196 

Endothelioma,         .         .         .  238,  242 

Enlargement  of  the  Brain,       .         .  16 

Head,      .  151,  203 

Epileptiform  Convulsions — See  Convul- 
sions. 
,,  General,         .  72,  157 

, ,  Localised,  79,123,155 

E  biology 2 

Influence  of  Age,      .         .     4,  201 
,,  Alcoholic  Excess,        3 

,,  Anxiety  and  Worry,    3 

Injury,  .  .  3 

,,  Micro-Organisms,       3 

External  Angular  Process,      .  256,  258 

Eyeball,  Trophic  Lesions  in,   .         .         169 


PAGE 

Fatty  Tumour,        ....         243 

Terrier,  Prof.  D.,  73,  89,  97,  105,  107,  152, 

173,  176,  190 

Fibrous  Tumour,    ....         243 

Field  of  Vision,      .         .         .         .92,  101 

Fissure  of  Rolando,  257,  258,  259,  260 

Sylvius,  .         .  260,  261 

,,         Parieto-Occipital,  .         .         262 

Forced  Movements,         ...  86 

Frontal    Lobe,    Symptoms     due    to 

Lesions  of,  ...  114,  151 

Fundus  Oculi,         .         .         .         .     36,  37 

Gait,  Reeling,  in  Cerebellar  Disease,  87,  188 
Galen,  Veins  of — See  Veins. 
General  Pathology  of  Brain  Tumours,  4 

Glabella,         ....  256,  258 

Gliomata, 222 

,,         Diagnostic  Features  of,   .         230 
,,         Vascularity  of,         .         .         226 
GUo-Sarcomata,      .         .  .         -17,  222 

Glycosiuria,     .         .         .         .         .         121 
Cowers,  Prof.  44,  52,  59,  107,  125,  130 

Graefe,  Von,  .         .         .         .     44,  53 

Hsemoirhage  in  Gliomata,       .         .  93,  102 
, ,  Cerebral,    Differential 

Diagnosis  from 
Tiunour,  143,  145 
,,  No  Neuritis  in,    60 

,,  at  Base,  a  cause 

of  Neuritis,        60 

Hare,  Mr.,  \\'rites  Chapter  XL,      .         253 

Head,  Enlargement  of,  .         .  151,  194 

Headache,  Causes  of, 

,,  Characters  of, 

,,  Diagnostic  Value  of, 

.,  Treatment  of. 

Hearing,  Derangements  of, 

Hemianopsia, 

, ,  Homonymous, 

,,  Nasal, 

,,  Temporal,       97 

Hemiplegia,   . 

,,  Altei'nate,    .    71, 

Hensen  and  Volckers,  Drs. 
Heubner,  Prof. 
Hiccough, 

Horsley,  Prof.  V.  .        74,  82,  251,  263,  264 
Hyaloid  Degeneration  of  Vessels,    .         225 
Hydrocephalus — Sec  Dropsy  of  Ven- 
tricles. 
Hj'perEesthesia,        .... 
Hypermetropia,     Differential     Diag- 
nosis from  Tumour, 
Hj-perpjTexia,         .... 
Hysteria,  Differential  Diagnosis  from 
Tumour,     ..... 


26 
25 
28 
251 
93,  102 
93 
93 
98 

,  99,  157,  162 

70 

168,  175,  182 

180 

212 

186 


90 


130 
120 


Fagge,  Dr  H., 
Fat,  Increase  of. 


.  27,  137 
119,  165 


133 


Increased  Intracranial  Pressure,      .  5 

,,  ,,  ,,       a  cause  of 

Papillitis,  53 
Indirect  Symptoms,         .         .         .  11 


INDEX. 


269 


Individuality,    its    Influence   on   the 

S)Tnptoms,  .  .  .  .  18 

Inferior  Frontal  Sulcus,  .         261 

Inion, 2fi6,  258 

Injury  a  cause  of  Tumour,       .  .     3,  201 

Insanity,  Differential  Diagnosis  from 

Tumour, 136 

Internal  Capsule,  Involvement  of,  154,  155, 
157,  158,  159,  172 
Intraparietal  Sulcus,        .         .  .         263 

Introduction,  ....  1 

Iodide  of  Potassium,       .         .         .         247 

Iodoform, 248 

Irritation,  a  cause  of  Optic  Neuritis,  53 

Irritative  Lesions,  ....  7 

Jackson,  Dr.  J.  Hughlings,  20,  38,  42,  45,  62, 
85,  102,  127,  139,  140,  252 
Jacksonian  Epilepsy,  72,  79,  123,  155,  202 
Jamieson,  Dr.  Allan,  .  .  .  33,  184 
Johnstone,  Dr.  Carlyle,  .         .         .         167 


Migraine,  Differential  Diagnosis  from 


KaUer  and  Pick,  Drs. 

Kidney  Disease — See  Bright's  Disease. 

Klebs,  Prof 


182 


229 


Latent  Tumours,    .         .  .         .  19 

Lautenbach,  Dr.     .         .  .         .         136 

Lawford,  Dr,  .  .  45 

Lawson,  Dr.  .         .         .         .         119 

Lead    Encephalopathy,    Differential 

Diagnosis  from  Tumour,      .         .         127 

Leber,  Prof 47,  51 

Lenticular  Nucleus,  Tumours  of,     171,  173 
Lesion,  Destroying  and  Discharging,  9 

Leslie,  Dr.      .....  25 

Lev/is,  Dr.  Be  van,  .         .         .         119 

Lloyd  and  Mills,  Drs.     .         .        30,  34,  90 
Local  Diagnosis,     .         .  .         .         146 

Localisation,  Cranio-Cerebral,  .         256 

,,  of  Fissures,  .  257,  261 

Localising  Symptoms,    6,  8,  15,  22,  23,  148 

Lung  Disease  a  cause  of  Brain  Tumours,       3 

Mackenzie,  Dr.  Stephen,  38,  42, 132,  195,  196 

M 'Bride,  Dr.  P 261 

McDowal,  Dr.  T.  W.      .         .         .         240 
Macewen,  Prof.      .         .         .  249,  263 

Medulla  Oblongata,  Tumoiu-s  of,     .         186 
Melanomata,  ....         243 

Melanotic  Sarcoma,         .  .     33,  38,  233 

M^ni^re's  Disease,  Differential  Diag- 
nosis from  Tumour  of  Cerebellum,        Vdl 
Meningitis,     Differential     Diagnosis 

from  Tumour,     .         .         .         .         136 

Mental  Symptoms,  .  108,114,141 

Method  of  Localisation,  .         .         258 

,,  Operating,     .         .         .         263 

Micro -Organisms  a  possible  cause  of 

Papillitis,     47 

,,  ,,  Tumour,        3 

Middle  Meningeal  Artery,       .  261,  262 


Tumour,      .... 

132 

Miller,  Mr.  A.  G.           .         . 

261 

Mills  and  Lloyd,  Drs.     . 

30,  34,  90 

Monoplegia,   .... 

184 

Morbid  Anatomy,  . 

199 

Motor  Area,  Tumours  of. 

l.o4 

, ,      Centres,  Destruction  of,  in 

Para- 

lysis,    , 

11 

, ,              , ,       Irritation  of,    . 

79 

,,              ,,       Position  of,      .   ■ 

73 

,,             ,,      Tumours  of,     . 

154 

,,      Derangements, 

68 

Movements,  Circus, 

86 

,,            Forced, 

86 

,,            Ehythmical, 

86 

Muscles,  Condition  of,  in  Paralysis,            71 

Nasal  Hemianopsia, 

98 

Neuralgic  Pains,    . 

.  90,  164 

Neuroma,       .... 

243 

Nodulus  Cursarius, 

173 

Nothnagel,  Prof.     . 

173,  198 

Nucleus  Caudatus,  Tumours  of. 

172 

„      Lenticularus,         ,, 

171,  173 

Nutrition,  State  of. 

119 

Obermeier,  Prof.     .         .         .2 

3.  235,  243 

Occipital  Lobe,  Tumours  of,    . 

156 

,,         Protuberance,  . 

256,  258 

Occupation,    .... 

4 

Operation,  Method  of,     . 

263 

Operative  Treatment, 

249,  254 

Ophthalmoplegia  Externa  Acuta, 

179 

Optic  Atrophy, 

43 

,,            ,,          from      pressure 

on 

Chiasma,    . 

59 

Optic   Lobes— <SV'e   Corpora    Qua 

dri- 

gemina. 

Optic  Neuritis, 

.     36,  50 

,,           ,,         Absence  of. 

23 

„           ,,         Causation  of,  . 

44,  46,  53 

,,           ,,         Diagnostic  Value, 

.    36,  40 

,,           ,,         in  Bright's  Disease,           125 

, ,            , ,         in  Meningitis, 

44 

,,           ,,         Post-Mortem  Appear- 

ances in. 

.     48,  49 

, ,            , ,         Treatment  of, 

252 

,,            ,,         Unilateral, 

36,  58,  99 

,,           ,,        Vision  in. 

37,  91,  93 

,,     Thalamus,  Tumours  of. 

176 

Osier,  Prof 

227 

Osseous  Tumours,  . 

243 

Pain,  Eelief  of,       . 

251 

Palliative  Measures, 

251 

Papillitis — See  OiDtic  Neuritis. 

Paralysis,  Causes  of,  .  .  .  68,  77 
,,  Diagnostic  Value  of,  .  72,  84 
, ,        from  Lesions  of  Cerebrum,  69 

,.  ,.        Corpus  Striatum,  172 

,,  ,,        Corpus  Callosum,    70 

Cortex,  .   69,  155 


270 


INDEX. 


PAGE 

Paralysis  from  Lesions  of  Crus  Cerebri,  71 

,,                    ,,              Pons  Varolii,  71 

,,        Post-Epileptic,         .         .  77 

,,        Temporary,     .         .         .  77,  154 

,,        Treatment  of,           .         .  252 

Parietal  Eminence,          .           256,  257,  261 

Parieto-Occipital  Fissure,         .         .  262 

Pathology  of  Brain  Tumours,            .     4,  199 

Pathological  Diagnosis:,  .          .          .  199 

Perforating  Tumour  of  the  Dura  Mater,  203 

Perimeter  Charts,  ....  92 

„               Importance  of,    .  101 

Phosphaturia,          .         .         .         .  121 

Pineal  Gland,  Tumours  of,      .           182,  243 

Pituitar}'  Body,  Tumours  of,  .          .  161 

Polyuria,         ....           121,  165 

Pons  Varolii,  Tumours  of,        174,  175,  182 

Post-Mortem  Appearances,     .         .  48 

Post-Parietal  Region,  Tumours  of,  156 

Precentral  Sulcus.  ....  261 

Prognosis,       .         .         .         .          .  245 

Psammomata,          ....  243 

Pseudo-Apoplectic  Attacks,     .         117,  202 

,,  ,,     Differential 

Diagnosis  of,  145 

,,     Treatment  of,  252 

Pseudo-Localising  Symptoms,          .  11 

Pulse  Frequency,    .         .         .         .  120 

Pyrexia, 119 

Rectal  Reflex,  Alterations  of,           .  87 

Red  Softening,        ....  236 

Reeling  Gait,          ....  87 
Renal  Disease — Hee  Bright's  Disease. 
Respiration,  Derangements  of. 
Retinitis,  Albuminuric,  . 
Rhythmical  ^lovements, 
Rolandic  Region,  Tumours  of, 
Rolando,  Fissure  of,         .          .          25/ 
Rosenthal,  Prof.     .... 
Ross,  Prof.     ..... 


PAGE 

Softening  due  to  Syphilis,        .         .         215 
Red,      .         .         .         .         236 

Spasms — 5'fc  Convulsions. 

Speech,  Derangements  of — See  Aphasia. 

Sudden  Death,        .         .         .         .         187 

Surgical  Interference,  Limits  of,      .         254 

SweiUng  of  the  Brain,     .  .  .  16 

Sylvius,  Fissure  of,         .         .         260,  261 

Symptoms,  Absence  of,  .         .         .  19 

,,  Analysis  of,  .         .         .  25 

,,  General  Pathology  of,    .  5 

,,  Indirect,        .  .  .  11 

,,  Localising,    .         .         .         148 

Syphilis  Cerebral,  Different  Forms  of,     209 

,,  ,,    Differential  Diagnosis  of,  143 

Sj-philitic  Tumours,         .         .         .         208 

„     Diagnostic  Features  of,  221 

,,  ,,     Treatment  of,       .  247 

Tactile  Sense,  Derangements  of,      .  88 

Taste,  Derangements  of,  .  .  106 

Temperature  Alterations,         .  .  119 

Temporal  Hemianopsia— -See  Hemianopsia. 


Sarcomata,     ..... 

,,  Diagnostic  Features  of, 

,,  Ti-eatment  of, 

SarsapariUa,   ..... 
Scalp,  Importance  of  in  Head  Opera- 
tions, ....         255, 
Schiifer,  Prof.  .        74,  89,  102,  105, 
Sci'ofulous  Tumours, 

,,  ,,     Diagnostic  Featui'es  of, 

,,  „     Treatment  of, 

Sensation,  Disorders  of, 

Sex, 

Sexual  Excitement, 
Sharkey,  Dr. 
Sight,  Derangements  of,  .         .  91 

,,      in  Optic  Neuritis,  .       37,  91,  93 

Skin,  Sensibility  of,         .         .         .  87 

Smell,  Derangements  of,  .         .         105 


121 
125 
86 
154 
260 
165 
104 

231 

233 
248 

248 

263 
107 
205 
20s 
248 
88 
201 
193 


Temporo-Sphenoidal  Lobe, 

262 

,,               .,               .,     Tumours  of, 

158 

Thane,  Prof. 

258 

Third  Nerve,  Nuclei  of. 

ISO 

Tongue,  Paralysis  of. 

187 

Tonic  Spasms, 

.  85, 

193 

Treatment,  Curative, 

248 

,,            Operative,     . 

249, 

254 

,,            Palliative,     . 

251 

Tremor,  Rhythmical, 

•  72, 

193 

Trephining,    .          .          .           249 

251 

254 

Tubercular  Tumour — 5'ee Scrofulous  Tumour. 

Tuning-Fork,  Diagnostic  use  of, 

105 

Turner,  Sir  William, 

257 

Urine,  Alterations  in,     . 

121 

Vaso-Motor  Disturbances, 

121 

,,            Theory  of  Optic  Neuritis, 

62 

Veins  of  Galen,  Obstruction  of. 

195 

Vertigo,          .... 

32 

,,       Diagnostic  Value  of,  . 

34 

Vessels,  Syphilitic  Disease  of. 

209, 

218 

Vision,  Acuitv  of — See  Sight. 

,,      Field  of— ,S'ee  Field. 

Visual  Aura, 

100, 

102 

5,     Centre, 

97 

Vomiting,       .... 

30 

„         Diagnostic  Value  of. 

31 

Weber,  Prof. 

104 

Wilson,  Dr.  C.        .         .         - 

258, 

260 

Wood,  Prof. 

208, 

248 

NVord-Blindness,     . 

116 

Word-Deafness, 

116 

Ziesrler,  Prof. 


236 


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